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During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
- A. If he has seemed depressed recently.
- B. If a drug overdose has ever occurred before.
- C. If he might have taken any other drugs.
- D. If he has a desire to quit taking drugs.
Correct Answer: C
Rationale: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.
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A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects?
- A. If I eat too many fruits, I'll get constipated.
- B. I need to take the medicine with food to avoid nausea.
- C. I have to get up slowly so I don't get dizzy.
- D. Sometimes I have to push myself because I'm sleepy.
Correct Answer: A
Rationale: Choice A reflects a need for further teaching as the client mistakenly believes that eating too many fruits causes constipation, showing a misunderstanding about dietary fiber's role in preventing constipation. Choices B, C, and D demonstrate accurate understanding of managing clozapine's adverse effects, such as taking it with food to avoid nausea, getting up slowly to prevent dizziness, and pushing oneself when feeling sleepy.
A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?
- A. Weight gain.
- B. Sexual dysfunction.
- C. Nausea.
- D. Constipation.
Correct Answer: B
Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.
A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). The nurse should include which information in the client's discharge teaching?
- A. This medication can cause physical dependence.
- B. It may take 2 to 4 weeks before you notice improvement.
- C. Avoid alcohol while taking this medication.
- D. You may experience sedation as a side effect.
Correct Answer: B
Rationale: Corrected Rationale: Buspirone takes time to become fully effective, so the client should be informed to expect a gradual improvement in anxiety symptoms. Choice A is incorrect because buspirone is not associated with physical dependence. Choice C is not directly related to buspirone but is generally a good practice when taking any medication. Choice D is less common with buspirone compared to other anxiety medications.
A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?
- A. Ask the client to sit down and relax.
- B. Administer a PRN dose of antipsychotic medication.
- C. Encourage the client to talk about what is making him anxious.
- D. Monitor the client for adverse reactions to the medication.
Correct Answer: B
Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.
The wife of a male client recently diagnosed with schizophrenia asks the nurse, 'What exactly is schizophrenia? Is my husband all right?' Which response is best for the nurse to provide to this family member?
- A. It sounds like you're worried about your husband. Let's sit down and talk.
- B. It is a chemical imbalance in the brain that causes disorganized thinking.
- C. Your husband will be just fine if he takes his medications regularly.
- D. I think you should talk to your husband's psychologist about this question.
Correct Answer: B
Rationale: The best response for the nurse to provide to the wife of the client diagnosed with schizophrenia is to offer factual information. Choice B is the correct answer as it explains that schizophrenia is a mental disorder characterized by a chemical imbalance in the brain that causes disorganized thinking. This response provides a simple and accurate explanation of the condition. Choices A, C, and D are incorrect because they do not directly address the wife's question about what schizophrenia is. Choice A focuses on emotional support rather than providing information about the disorder. Choice C gives false reassurance without addressing the nature of schizophrenia. Choice D deflects the question by suggesting the wife speak to the psychologist, missing an opportunity to educate and support the family member.