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During an exacerbation of schizophrenia symptoms, which intervention should the nurse prioritize for a client with a history of schizophrenia?
- A. Encourage adherence to the medication regimen.
- B. Increase social interactions with peers.
- C. Provide a high-stimulation environment.
- D. Assess for safety risks related to the exacerbation.
Correct Answer: D
Rationale: During an exacerbation of schizophrenia symptoms, the nurse should prioritize assessing for safety risks. This is critical because individuals with schizophrenia may experience heightened risks to themselves or others during this period. Encouraging adherence to the medication regimen (Choice A) is important but ensuring immediate safety takes precedence. Increasing social interactions with peers (Choice B) and providing a high-stimulation environment (Choice C) can potentially exacerbate symptoms and should be avoided during an exacerbation.
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An adolescent with anorexia nervosa is participating in a cognitive-behavioral therapy (CBT) program. Which behavior indicates that the therapy is effective?
- A. Client adheres to a meal plan and gains weight.
- B. Client discusses the impact of the disorder on family.
- C. Client expresses a desire to change behavior.
- D. Client reduces the frequency of binge eating.
Correct Answer: A
Rationale: In treating anorexia nervosa with cognitive-behavioral therapy (CBT), the primary goals are to normalize eating behaviors and achieve weight restoration. Therefore, adherence to a meal plan and weight gain are crucial indicators of treatment effectiveness. While discussing the impact of the disorder on the family (Choice B) can be beneficial for therapy, it may not directly indicate the effectiveness of CBT in treating anorexia nervosa. Expressing a desire to change behavior (Choice C) is a positive step, but actual behavioral changes such as adhering to a meal plan are more indicative of progress. Reducing the frequency of binge eating (Choice D) is more relevant for other eating disorders like bulimia nervosa, not anorexia nervosa.
The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?
- A. Completely abstain from heroin or cocaine use.
- B. Remain alcohol-free for 12 hours prior to the first dose.
- C. Attend monthly meetings of Alcoholics Anonymous.
- D. Admit to others that he is a substance user.
Correct Answer: B
Rationale: The correct answer is B: "Remain alcohol-free for 12 hours prior to the first dose." It is essential for the client to understand the importance of abstaining from alcohol for at least 12 hours before starting disulfiram to prevent potential adverse reactions. Choice A is incorrect because disulfiram is specifically used to deter alcohol consumption, not heroin or cocaine use. Choice C is not directly related to the initiation of disulfiram therapy and attending AA meetings is not a requirement for taking disulfiram. Choice D is irrelevant and unnecessary for the initiation of disulfiram therapy.
A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
- A. Excessive CNS stimulation will be reduced.
- B. Co-dependent behaviors will be decreased.
- C. Client's level of consciousness will increase.
- D. Client will not demonstrate cross-addiction.
Correct Answer: A
Rationale: The correct answer is A: 'Excessive CNS stimulation will be reduced.' During benzodiazepine withdrawal, the priority is to manage symptoms such as CNS hyperactivity, which can include agitation, anxiety, and seizures. Substitution therapy aims to minimize these withdrawal symptoms by providing a safer alternative to the benzodiazepine. Options B, C, and D are not the highest priority during benzodiazepine withdrawal. Decreasing co-dependent behaviors, increasing the client's level of consciousness, and preventing cross-addiction are important aspects of care but are not as critical as managing the potentially severe CNS stimulation.
During the admission assessment of an underweight adolescent with depression on a psychiatric unit, the nurse finds a potassium level of 2.9 mEq/dl. Which finding requires notification to the healthcare provider?
- A. Potassium level of 2.9 mEq/dl.
- B. BP of 110/70 mmHg.
- C. WBC of 10,000 mm³.
- D. Body mass index of 21.
Correct Answer: A
Rationale: A potassium level of 2.9 mEq/dl is critically low, indicating hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Prompt notification to the healthcare provider is essential for immediate intervention.
Choice B, a blood pressure of 110/70 mmHg, is within the normal range. Choice C, a white blood cell count of 10,000 mm³, is also within normal limits and is not a concerning finding in this context. Choice D, a body mass index of 21, may indicate being underweight but is not as urgent as addressing the critically low potassium level.
The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?
- A. Lithium (Lithotabs).
- B. Benztropine (Cogentin).
- C. Alprazolam (Xanax).
- D. Magnesium (Milk of Magnesia).
Correct Answer: B
Rationale: The correct answer is Benztropine (Cogentin). Benztropine is commonly prescribed to manage side effects of antipsychotic medications. Therefore, if the antipsychotic medication is discontinued, there would be no need for Benztropine. Lithium is a mood stabilizer used in bipolar disorder, not directly related to antipsychotic use. Alprazolam is an anxiolytic, and Magnesium (Milk of Magnesia) is a laxative, neither of which is typically associated with antipsychotic medication use.