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As part of an interdisciplinary team, a nurse is assisting in developing the plan of care for a client with a delusional disorder. Which of the following would the team be least likely to include in the plan?
- A. Insight-oriented therapy
- B. Psychoeducation
- C. Cognitive therapy
- D. Support therapy
Correct Answer: A
Rationale: Insight-oriented therapy (A) is least likely for delusional disorder, as clients often lack insight into their delusions, making this approach less effective. Psychoeducation (B), cognitive therapy (C), and support therapy (D) are more practical for managing symptoms and coping.
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The nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for which of the following?
- A. Weight loss
- B. Torticollis
- C. Hypoglycemia
- D. Tardive dyskinesia
Correct Answer: D
Rationale: Tardive dyskinesia (D), a potentially irreversible side effect of long-term use of typical antipsychotics like chlorpromazine, involves involuntary movements and requires ongoing monitoring. Weight loss (A) is unlikely (weight gain is more common), torticollis (B) is an acute dystonia, and hypoglycemia (C) is not a typical side effect.
The nurse is caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would the nurse anticipate as being prescribed for this client?
- A. Lithium
- B. Haloperidol
- C. Chlorpromazine
- D. Clozapine
Correct Answer: D
Rationale: Clozapine (D) is effective for schizoaffective disorder, addressing both psychotic and mood symptoms, especially in treatment-resistant cases. Lithium (A) is primarily for bipolar disorder, and haloperidol (B) and chlorpromazine (C) are less effective for mood components.
When obtaining a client?s history, the nurse determines that the client has been experiencing delusions and hallucinations for the past 3 months, which has caused some problems in his ability to function on a daily basis at work. He also is exhibiting catatonic excitement, echopraxia, loose associations, and pressured speech. The nurse suspects which of the following?
- A. Schizophrenia
- B. Schizoaffective disorder
- C. Brief Psychotic disorder
- D. Schizophreniform disorder
Correct Answer: D
Rationale: Schizophreniform disorder (D) involves schizophrenia-like symptoms (delusions, hallucinations, disorganized speech, catatonia) lasting 1?6 months, matching the client?s 3-month duration. Schizophrenia (A) requires 6+ months, schizoaffective disorder (B) requires mood episodes, and brief psychotic disorder (C) lasts less than 1 month.
The nurse is caring for a client who was diagnosed with schizoaffective disorder. Based on the nurse?s understanding of this disorder, the nurse develops a plan of care to address which issue as the top priority?
- A. Suicide
- B. Aggression
- C. Substance abuse
- D. Eating disorder
Correct Answer: A
Rationale: Suicide (A) is the top priority in schizoaffective disorder due to the combined risk of mood disturbances (e.g., depression) and psychosis, both of which elevate suicide risk. Aggression (B), substance abuse (C), and eating disorders (D) are concerns but less immediate unless actively present.
The nurse is caring for a client who has been taking clozapine (Clozaril) for 2 weeks. The client tells the nurse, My throat is sore, and I feel weak. The nurse assesses the client?s vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?
- A. A white blood cell count
- B. Liver function studies
- C. Serum potassium level
- D. Serum sodium level
Correct Answer: A
Rationale: Clozapine (A) carries a risk of agranulocytosis, a potentially life-threatening drop in white blood cells, presenting with symptoms like sore throat, weakness, and fever. Monitoring white blood cell counts is critical. Liver function (B), potassium (C), and sodium (D) levels are less relevant to these symptoms.