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A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse’s priority at this time?
- A. Contact the adolescent’s parents
- B. Suggest the adolescent join support groups
- C. Ask the adolescent if he is considering hurting himself
- D. Determine when the adolescent’s change in behavior began
Correct Answer: C
Rationale: The correct answer is C: Ask the adolescent if he is considering hurting himself. This is the priority intervention because it addresses the immediate safety and well-being of the adolescent. By directly asking about thoughts of self-harm, the nurse can assess the risk of suicide and provide appropriate interventions if necessary. Contacting the parents (choice A) can be important but not the priority in this situation. Suggesting support groups (choice B) and determining when the behavior changes began (choice D) are important steps but not as urgent as assessing for suicidal ideation.
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A nurse in a psychiatric unit is planning care for a client who has paranoid personality disorder. Which of the following interventions should the nurse include?
- A. Encourage group therapy participation
- B. Avoid challenging the client’s paranoid beliefs
- C. Maintain eye contact during conversations
- D. Use humor to reduce the client’s anxiety
Correct Answer: B
Rationale: The correct answer is B: Avoid challenging the client’s paranoid beliefs. This is essential because challenging the client's beliefs can lead to increased defensiveness and mistrust. Instead, the nurse should validate the client's feelings without reinforcing the delusions. Encouraging group therapy (choice A) may exacerbate paranoia by increasing feelings of being scrutinized. Maintaining eye contact (choice C) may be perceived as threatening. Using humor (choice D) could be misinterpreted and lead to further distrust.
A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?
- A. This medication is given to help with extrapyramidal side effects
- B. This medication is given to help with your depression
- C. Benztropine helps alleviate your hallucinations
- D. Benztropine is used to counteract your tachycardia
Correct Answer: A
Rationale: Correct Answer: A: This medication is given to help with extrapyramidal side effects.
Rationale:
1. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal side effects (EPS) caused by antipsychotic medications.
2. EPS include symptoms like tremors, muscle stiffness, and restlessness, which can occur with antipsychotic use.
3. By blocking certain neurotransmitters in the brain, benztropine helps alleviate these side effects.
4. Other choices are incorrect:
- B: Benztropine does not treat depression, as it is not an antidepressant.
- C: Benztropine does not directly address hallucinations, which are typically managed with antipsychotic medications.
- D: Benztropine does not specifically target tachycardia, which may be a side effect of other medications but not the primary indication for benztropine use.
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
- A. Place the client in a group therapy session
- B. Rotate staff members who work with the client
- C. Encourage the client to participate in physical activities
- D. Distract the client with increased environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to participate in physical activities. Physical activities can help to channel the excess energy and agitation associated with manic episodes in bipolar disorder. Exercise can help reduce stress, improve mood, and promote better sleep patterns. Group therapy (A) may not be appropriate during a manic episode as the client may have difficulty focusing and could disrupt the session. Rotating staff members (B) could lead to inconsistency in care and may worsen the client's symptoms. Distracting the client with increased environmental stimuli (D) could exacerbate agitation and overstimulation. It is important to provide a structured and safe outlet for the client's energy, hence physical activities are the most appropriate intervention in this scenario.
A nurse is providing discharge teaching to the parents of a child who has ADHD and a prescription for methylphenidate. Which of the following instructions should the nurse include?
- A. Administer the medication at bedtime
- B. Monitor the child’s weight frequently
- C. Give the medication with milk
- D. Discontinue the medication if insomnia occurs
Correct Answer: B
Rationale: The correct answer is B: Monitor the child’s weight frequently. This is important because methylphenidate, a stimulant used to treat ADHD, can potentially lead to appetite suppression and weight loss in children. Regular monitoring of the child's weight can help identify any significant changes and allow for appropriate interventions if needed.
Choice A is incorrect because administering the medication at bedtime can lead to insomnia due to its stimulant effects. Choice C is incorrect as there is no specific recommendation to give the medication with milk. Choice D is incorrect because insomnia is a common side effect of methylphenidate and does not necessarily warrant discontinuation of the medication unless severe or persistent.
A nurse is planning care for a client who has bipolar disorder and is experiencing a depressive episode. Which of the following interventions should the nurse include?
- A. Encourage excessive physical activity
- B. Provide frequent rest periods
- C. Discourage interaction with others
- D. Implement a rigid daily routine
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During a depressive episode in bipolar disorder, the client may experience fatigue and lack of motivation. Providing frequent rest periods allows for adequate relaxation and helps to conserve energy. This intervention supports the client in managing their symptoms and promotes self-care.
A: Encouraging excessive physical activity may exacerbate fatigue and worsen symptoms during a depressive episode.
C: Discouraging interaction with others may increase feelings of isolation and worsen depressive symptoms.
D: Implementing a rigid daily routine may add pressure and stress to the client, which can be counterproductive during a depressive episode.