Nokea
The client has been taking lithium and fluoxetine (Prozac) for almost a week. During today's assessment, the nurse notes a temperature of 39°C, muscle rigidity, and confusion. The client's signs and symptoms suggest:
- A. Dystonic reactions
- B. Bradykinesic side effects
- C. Extrapyramidal side effects
- D. Neuroleptic malignant syndrome
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). This is indicated by the client's elevated temperature, muscle rigidity, and confusion, which are classic symptoms of NMS. NMS is a serious, potentially life-threatening condition associated with the use of antipsychotic medications like lithium and fluoxetine. The onset of NMS is often rapid and can lead to severe complications if not treated promptly. Dystonic reactions (choice A) involve sudden and involuntary muscle contractions, which are not consistent with the client's symptoms. Bradykinesic side effects (choice B) refer to slowed movements, which are not present in this case. Extrapyramidal side effects (choice C) typically include symptoms like tremors, stiffness, and restlessness, but do not encompass the combination of symptoms seen in NMS.
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A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after experiencing an event in which the most recent episodes of violence were related to feeling 'upset' over a job loss. What type of therapy would provide the greatest help to the abuser?
- A. Voluntary individual or group therapy
- B. Court-ordered individual or group therapy
- C. Voluntary couples or family therapy
- D. None of the above
Correct Answer: A
Rationale: The correct answer is A: Voluntary individual or group therapy. This type of therapy would be most helpful as it focuses on addressing the abuser's personal issues and behaviors, such as managing frustration and anger. By participating voluntarily, the abuser is more likely to be open to introspection and change.
Summary of other choices:
B: Court-ordered therapy may not be as effective as voluntary therapy, as the abuser may feel forced and less motivated to engage in the process.
C: Couples or family therapy may not be appropriate initially as the abuser needs to work on personal issues first before addressing relationship dynamics.
D: None of the above is incorrect as voluntary individual or group therapy is the most suitable option for addressing the abuser's behavior.
Which theory of etiology of Alzheimer's disease, suggested by current research, might the nurse use to help a family understand that this disorder is not of psychosocial origin? Alzheimer's disease is associated with:
- A. @-amyloid protein deposits in the brain
- B. Abnormal serotonin reuptake
- C. Excessive acetylcholine in the frontal cortex
- D. Prion infection of gray matter
Correct Answer: A
Rationale: The correct answer is A: @-amyloid protein deposits in the brain. This theory of Alzheimer's etiology is supported by current research, indicating that the accumulation of @-amyloid protein plaques in the brain is a key characteristic of the disease. These plaques lead to neuronal damage and cognitive decline. Option B, abnormal serotonin reuptake, is not associated with Alzheimer's. Option C, excessive acetylcholine in the frontal cortex, is incorrect as Alzheimer's is characterized by acetylcholine deficiency. Option D, prion infection of gray matter, is not linked to Alzheimer's disease. In summary, the presence of @-amyloid protein deposits in the brain is a key feature of Alzheimer's pathology, distinguishing it from psychosocial origins.
An individual accompanied by a friend was brought by ambulance to the emergency room. A nurse notes that the patient's skin is flushed and dry. Further assessment reveals the patient has not voided or ingested food or fluid in 18 hours. Temperature, pulse, blood pressure, and respirations are elevated, and sensorium alternates between clouded and clear. The physician diagnoses fever of unknown origin. Because the patient is restless and agitated, the plan is to make an effort to orally hydrate before attempting to start an IV line. The intervention most likely to be effective will be:
- A. placing a pitcher of water at the patient's bedside.
- B. placing a "force fluids"Â sign at the head of the bed.
- C. asking the friend to give the patient a drink whenever the patient is alert.
- D. staying with the patient to ensure that a glass of liquid is ingested once every hour.
Correct Answer: D
Rationale: The correct answer is D: staying with the patient to ensure that a glass of liquid is ingested once every hour. This choice is the most effective intervention because the patient is in a state of restlessness and agitation, making it crucial to closely monitor fluid intake. By staying with the patient and ensuring regular liquid consumption, the nurse can help maintain hydration and potentially alleviate symptoms.
Choice A (placing a pitcher of water at the patient's bedside) may not be effective as the patient may not be able to independently drink the water when needed. Choice B (placing a "force fluids" sign at the head of the bed) might not address the patient's agitation and restlessness and could lead to increased anxiety. Choice C (asking the friend to give the patient a drink whenever the patient is alert) may not provide consistent monitoring and support needed for the patient's condition.
Therefore, choice D is the best option as it addresses the patient's need for hydration, agitation, and restlessness effectively
The first step in the creation of a therapeutic alliance between a nurse and a patient with a maladaptive response to eating regulation is:
- A. formulation of a nurse-patient contract.
- B. resolution of conflicts with family members.
- C. nurse and patient will agree on perception of patient's body.
- D. the means of stabilizing the patient's nutritional status will be specified.
Correct Answer: A
Rationale: The correct answer is A: formulation of a nurse-patient contract. This is because establishing a clear agreement outlining the roles, responsibilities, and boundaries between the nurse and patient is crucial in building trust and collaboration. It sets the foundation for a therapeutic alliance by promoting mutual understanding and shared goals.
Summary:
B: Resolving conflicts with family members may be important for overall well-being but is not the first step in creating a therapeutic alliance.
C: Agreeing on the patient's body perception is important but does not address the fundamental establishment of trust through a contract.
D: Specifying means of stabilizing nutritional status is essential but comes after the initial agreement on roles and responsibilities.
A client who is hospitalized with anorexia nervosa states during a one-to-one session with the nurse, 'I'm freaking out. I'm losing it.' Which nurse response would be most therapeutic at this time?
- A. Would you feel better if I called your parents?'
- B. Just sit here and relax and maintain control.'
- C. Let me sit with you for a while.'
- D. Tell me what thoughts are going through your head.'
Correct Answer: D
Rationale: The correct answer is D because it encourages the client to express their thoughts and feelings, aiding in the therapeutic process. This response promotes open communication and allows the nurse to assess the client's mental state. Choice A may not address the client's immediate distress and could potentially escalate anxiety. Choice B dismisses the client's feelings and does not address the issue. Choice C offers support but does not actively encourage the client to verbalize their thoughts, which is crucial in addressing underlying issues.