An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?
- A. Sore throat
- B. Weight loss
- C. Constipation
- D. Lightheadedness
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Clozapine can cause agranulocytosis, a potentially life-threatening condition characterized by a decrease in white blood cells. Sore throat could indicate an infection, necessitating immediate medical attention to monitor for agranulocytosis. Weight loss (B) and constipation (C) are common side effects of clozapine but do not require immediate reporting. Lightheadedness (D) may be a side effect but not as urgent as a sore throat in this case.
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What assessment question should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply.
- A. How did you cope when your father deployed with the Army for a year in Iraq?
- B. Who did you go to for advice while your father was away for a year in Iraq?
- C. How do you feel about talking to a mental health counselor?
- D. Where do you see yourself in 10 years?
Correct Answer: C
Rationale: The correct answer is C: How do you feel about talking to a mental health counselor? This question is crucial in assessing a teenager's mental health resilience as it directly addresses their willingness to seek professional help and their attitude towards mental health support. By asking this question, the nurse can gauge the teenager's openness to counseling, which is an important aspect of resilience-building.
Choices A, B, and D are incorrect because they do not directly assess the teenager's mental health resilience. Questioning coping strategies (A), seeking advice (B), or future aspirations (D) may provide valuable information, but they do not specifically address the individual's attitude towards seeking professional mental health support, which is essential for determining resilience in this context.
While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique?
- A. Initiate a non-threatening conversation with the client.
- B. Dialog about the ineffectiveness of his interactions.
- C. Allow the client to identify the way he interacts.
- D. Discuss the client’s feelings when he responds.
Correct Answer: C
Rationale: The main goal of the therapeutic technique demonstrated by the RN is to allow the client to identify the way he interacts (Choice C). By mirroring the client's behaviors, the RN provides a reflection of the client's own actions, which can help the client become more self-aware of how he presents himself. This can lead to insight into his own behavior and communication style, facilitating personal growth and potential behavior change.
Choice A is incorrect because the main goal is not just to initiate conversation, but to promote self-awareness. Choice B is incorrect as the focus is not on discussing the ineffectiveness of interactions but rather on self-identification. Choice D is incorrect as the main focus is not on discussing the client's feelings but on allowing the client to recognize his own behavior patterns.
The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
- A. Tell me what you think should happen.
- B. How serious was the collision?
- C. What do you think you should do?
- D. Call for transportation to the hospital.
Correct Answer: D
Rationale: The correct response is D: Call for transportation to the hospital. In this crisis situation, the most urgent need is for the employee to be with her child at the hospital. By providing transportation, the nurse ensures that the employee can reach her child quickly and offer support. This action demonstrates empathy and prioritizes the employee's immediate needs.
A: Asking the employee what she thinks should happen may not be the most appropriate response in a crisis where decisive action is needed.
B: Inquiring about the seriousness of the collision is secondary to ensuring the employee can reach her child at the hospital.
C: Asking the employee what she thinks she should do puts the onus on her to make a decision when she may be in distress and unable to think clearly.
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Place in a side-lying position with head of bed elevated.
- B. Administer disulfiram (Antabuse) immediately
- C. Give lorazepam (Ativan) PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: A
Rationale: The correct answer is A: Place in a side-lying position with head of bed elevated. This is the priority intervention because the client is difficult to arouse, indicating potential risk for airway compromise and aspiration due to the head injury and elevated BAL. Placing the client in a side-lying position with the head of the bed elevated helps prevent aspiration and promotes optimal airway management. Administering disulfiram (choice B) is not indicated as the priority intervention in this acute situation. Giving lorazepam (choice C) for signs of withdrawal may further depress the client's level of consciousness and is not the priority at this time. Providing thiamine and folate supplements (choice D) is important for alcohol-related deficiencies but does not address the immediate risk of airway compromise.
When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that:
- A. Medications provided are ineffective.
- B. Nurses are trying to control their minds.
- C. The medications will make them sick.
- D. They are not actually ill.
Correct Answer: D
Rationale: The correct answer is D: They are not actually ill. Anosognosia is a symptom of schizophrenia where patients lack awareness of their illness. This leads them to deny their condition and refuse treatment. Choice A is incorrect as it assumes patients are aware of the medication's effectiveness. Choice B is incorrect as it introduces a paranoid belief not related to anosognosia. Choice C is incorrect as it focuses on physical side effects, not denial of illness.