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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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The client is preparing to discontinue the use of a sedative-hypnotic medication. Which instruction should the nurse include?
- A. "You may experience withdrawal symptoms; these are usually mild."
- B. "The medication will need to be gradually tapered off."
- C. "You should increase your caffeine intake to stay alert."
- D. "There should be no change in your sleep patterns during discontinuation."
Correct Answer: B
Rationale: When discontinuing sedative-hypnotic medications, it is crucial to gradually taper them off to prevent withdrawal symptoms. Choice A is incorrect because withdrawal symptoms can be severe, not always mild. Choice C is incorrect as increasing caffeine intake can exacerbate sleep disturbances. Choice D is incorrect because changes in sleep patterns are expected during discontinuation of sedative-hypnotic medications.
A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zyprexa), because of the side effects he experienced when he took it previously. Which statement is best for the RN to provide?
- A. The medication has side effects, but they are manageable.
- B. If you refuse the medication, you will be restrained.
- C. The doctor will try another medication if this one is not effective.
- D. It is important to take the medication as prescribed for it to be effective.
Correct Answer: A
Rationale: It is essential for the nurse to address the client's concerns about the side effects of the medication. By acknowledging the side effects and reassuring the client that they are manageable, the nurse empowers the client to make an informed decision about their treatment. This approach fosters trust between the client and the healthcare provider, promotes open communication, and supports treatment adherence. Choices B and D are not appropriate as they do not address the client's specific concern about the side effects or offer constructive support. Choice C is premature as switching medications should be considered after exploring ways to manage the side effects of the current medication.
What is the most appropriate intervention by the RN to address a client with obsessive-compulsive disorder (OCD) who repeatedly checks to see if the door is locked and asks for reassurance?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: Setting a specific limit on the checking behavior is the most appropriate intervention for a client with OCD who repeatedly checks the door and seeks reassurance. This approach helps the client gradually reduce the compulsive behavior, promotes independence, and supports progress in treatment. Choice B is not the most suitable intervention as it does not directly address the compulsive checking behavior. Choice C, providing consistent reassurance, may reinforce the compulsive behavior and hinder treatment progress. Choice D of ignoring the behavior does not actively assist the client in managing their symptoms and addressing the underlying disorder.
Which actions are likely to help promote the self-esteem of a male client with major depression?
- A. Ask the client about his long-term goals.
- B. Discuss the challenges of his medical condition.
- C. Include the client in determining treatment protocol.
- D. Encourage the client to engage in recreational therapy.
Correct Answer: C
Rationale: Including the client in determining the treatment protocol is the most suitable action to promote the self-esteem of a male client with major depression. This approach empowers the client, involves him in decision-making regarding his care, and fosters a sense of control and self-worth. Option A, asking about his long-term goals, may not directly address his immediate self-esteem needs related to his current condition. Option B, discussing the challenges of his medical condition, may inadvertently focus on negative aspects and potentially lower self-esteem. Option D, encouraging engagement in recreational therapy, is beneficial but may not directly address the client's sense of control and self-worth in decision-making related to his treatment.
The RN on the evening shift receives a report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?
- A. Hold all bedtime medications.
- B. Keep the client NPO after midnight.
- C. Implement elopement precautions.
- D. Give the client an enema at bedtime.
Correct Answer: B
Rationale: Keeping the client NPO after midnight is the appropriate intervention before ECT to prevent complications during the procedure. Withholding food and fluids reduces the risk of aspiration and helps ensure the safety of the client. Option A (Hold all bedtime medications) is incorrect because medications may need to be given as prescribed unless specified otherwise by the healthcare provider. Option C (Implement elopement precautions) is unrelated to preparing a client for ECT and focuses on preventing a client from leaving the treatment area. Option D (Give the client an enema at bedtime) is unnecessary and not a standard pre-ECT preparation, making it an incorrect choice.