Nokea
A writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially, the nurse should plan this for a manic client:
- A. Set realistic limits to the client's behavior
- B. Repeat verbal instructions as often as needed
- C. Allow the client to express feelings to relieve tension
- D. Assign a staff member to be with the client at all times to help maintain control
Correct Answer: A
Rationale: For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client's behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.
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A client with schizophrenia is taking loxapine. Which of the following findings should the nurse identify as the most important to report?
- A. Spasms of the tongue and face
- B. Orthostatic hypotension
- C. Dry mouth
- D. Increased appetite
Correct Answer: A
Rationale: Spasms of the muscles of the tongue, face, neck, and back are indicative of acute dystonia, an extrapyramidal manifestation associated with loxapine use. Acute dystonia is a serious condition that can lead to airway obstruction and respiratory compromise. Therefore, the nurse should prioritize reporting this finding to prevent potential harm to the client. Orthostatic hypotension, dry mouth, and increased appetite are common side effects of antipsychotic medications but are not as immediately life-threatening as acute dystonia. Monitoring and managing these side effects are essential for the client's overall well-being, but they do not pose the same level of urgency as addressing acute dystonia.
The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
- A. To tell the client this is not true; that we all have a purpose in life.
- B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
- C. To reassure the client that you know how the client is feeling and that things will get better.
- D. To identify recent behaviors or accomplishments that demonstrate skill ability.
Correct Answer: C
Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.
What is a key principle of patient teaching that must take place to ensure patient safety?
- A. Family members should be present
- B. Teaching must be documented
- C. Understanding must be confirmed
- D. Teaching should be provided by multiple staff members
Correct Answer: C
Rationale: A key principle of patient teaching that ensures patient safety is the confirmation of understanding. To ensure patient safety, it is crucial to confirm that the patient comprehends the information provided. This confirmation can be achieved by having the patient repeat back the information or demonstrate understanding through return demonstration. Documenting the patient's understanding is essential to track the effectiveness of the teaching session and ensure that the patient is equipped with the necessary knowledge for their safety. Family members being present or having multiple staff members provide teaching may be beneficial in certain situations, but the primary focus should be on confirming the patient's understanding to enhance safety and promote effective learning.
A client with a new prescription for lithium carbonate for bipolar disorder is being educated by a nurse on early indications of toxicity. The nurse should include which of the following manifestations in the teachings?
- A. Constipation
- B. Polyuria
- C. Rash
- D. Tinnitus
Correct Answer: B
Rationale: Polyuria is a crucial early indication of lithium toxicity. It results from the drug's effect on the kidneys, leading to increased urine output. This is a significant symptom to monitor as it can indicate potential toxicity. Constipation, rash, and tinnitus are not typically associated with early indications of lithium toxicity. Constipation is more commonly seen as a side effect of some medications, while rash and tinnitus are not specific indicators of lithium toxicity.
The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis?
- A. Inability to react appropriately to social cues
- B. Engages in repetitive behaviors
- C. Comprehends language well beyond the complexity expected for age
- D. Displays self-destructive behavior
Correct Answer: C
Rationale: The correct answer is 'Comprehends language well beyond the complexity expected for age.' Children with autism spectrum disorder typically struggle with language and communication skills, so comprehending language well beyond their age level would not align with the diagnosis of ASD. This finding could indicate other developmental strengths or delays. Choices A, B, and D are more commonly associated with ASD - the inability to react appropriately to social cues, engaging in repetitive behaviors, and displaying self-destructive behavior are typical manifestations of autism spectrum disorder.