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Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.
- A. Hold his medication and contact his prescriber.
- B. Wipe him with a washcloth wet with cold water or alcohol.
- C. Administer a medication such as benztropine IM to correct this dystonic reaction.
- D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.
Correct Answer: C
Rationale: The correct answer is C: Administer a medication such as benztropine IM to correct this dystonic reaction. The patient is exhibiting symptoms of acute dystonia, a side effect of haloperidol. Benztropine is a commonly used anticholinergic medication that can quickly reverse these symptoms. It is important to address this promptly to prevent further complications. Holding the medication and contacting the prescriber (choice A) can be done after addressing the acute symptoms. Wiping the patient with cold water or alcohol (choice B) may provide temporary relief but does not address the underlying cause. Reassuring the patient about tardive dyskinesia (choice D) is incorrect as the current symptoms are not related to tardive dyskinesia.
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The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?
- A. Alprazolam (Xanax)
- B. Benztropine (Cogentin)
- C. Magnesium (Milk of Magnesia)
- D. Lithium (Lithotabs)
Correct Answer: B
Rationale: The correct answer is B: Benztropine (Cogentin). Benztropine is a medication commonly used to treat extrapyramidal side effects caused by antipsychotic medications. If the antipsychotic medication is discontinued, there is no longer a need for Benztropine. Alprazolam (A) is used to treat anxiety and should not be automatically discontinued. Magnesium (C) is a laxative and unrelated to bipolar disorder treatment. Lithium (D) is a mood stabilizer commonly used in bipolar disorder treatment and should not be discontinued without a healthcare provider's guidance.
James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for day shift and anxiously reports, “Last night, demons came to my room and tried to rape me.†Which response would be most therapeutic?
- A. There are no such things as demons. What you saw were hallucinations.
- B. It is not possible for anyone to enter your room at night. You are safe here.
- C. You seem very upset. Please tell me more about what you experienced last night.
- D. That must have been very frightening, but we’ll check on you at night and you’ll be safe.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and active listening. By acknowledging James's feelings and inviting him to share more about his experience, the response validates his emotions and fosters trust. This approach helps build a therapeutic relationship and allows for a deeper exploration of his hallucinations. Options A and B invalidate James's experience and may increase his distress. Option D offers reassurance but lacks the immediate emotional support James needs.
Which statement demonstrates a well-structured attempt at limit setting?
- A. Hitting me when you are angry is unacceptable.
- B. I expect you to behave yourself during dinner.
- C. Come here, right now!
- D. Good boys don’t bite.
Correct Answer: A
Rationale: The correct answer is A because it clearly communicates the behavior that is unacceptable (hitting when angry) and sets a clear boundary. It addresses the specific behavior and its consequences without being vague or ambiguous. Choice B lacks specificity, choice C is a command without explaining the reason for the request, and choice D uses shaming language which is not effective in setting limits. Choices E, F, and G are irrelevant as they are not provided. Overall, choice A demonstrates a well-structured attempt at limit setting by being clear, specific, and focusing on the behavior that needs to change.
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.
Which statement made by a patient prescribed bupropion (Wellbutrin) demonstrates that the medication education the patient received was effective? Select all that apply.
- A. I hope Wellbutrin will help my depression and also help me to finally quit smoking.
- B. I’m happy to hear that I won’t need to worry too much about weight gain.
- C. It’s okay to take Wellbutrin since I haven’t had a seizure in 6 months.
- D. I need to be careful about driving since the medication could make me drowsy.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates the patient understands the dual purpose of bupropion - treating depression and aiding smoking cessation. This indicates comprehension of the medication's intended effects. Choice B is incorrect as weight loss is a common side effect, not weight gain. Choice C is incorrect as a history of seizures is a contraindication for bupropion. Choice D is incorrect as bupropion is not known to cause drowsiness.