Nokea
The nurse is caring for a client diagnosed with delirium. What does the nurse know to be true of delirium?
- A. It is incurable.
- B. It is a sudden, transient state.
- C. It has a gradual onset.
- D. It is considered permanent.
Correct Answer: B
Rationale: Delirium is a sudden, transient state of confusion. The period of confusion depends on the cause of the delirium. Treating the underlying medical condition usually restores mental function.
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The nurse is instructing the parents of a 21-year-old with schizophrenia who hears voices. Which response by the parent to the child validates that the parent understands the discharge teaching?
- A. The parent states 'Does the person speaking have a name?'
- B. The parent states 'The person speaking to you is bad, but you are good.'
- C. The parent states 'The voice is not real. We have talked about this before.'
- D. The parent states 'I do not hear the voices, but what are they telling you?'
Correct Answer: D
Rationale: The parent is most correct to state not hearing the voices but then asking the client to share what the voices are saying. By identifying the content of the hallucinations, the parent can determine the safety of the client or if others are in jeopardy. Also, the parent is correct to call the auditory hallucinations by the term 'the voices.'
Which of the following is the primary reason for monitoring food and fluid intake and toilet patterns of a client with mental disabilities?
- A. Regular checkup
- B. To identify problems
- C. To determine common symptoms
- D. Physician's record
Correct Answer: B
Rationale: The nurse monitors food and fluid intake and toilet patterns because data collection facilitates problem identification, not as part of a regular checkup or for determining common symptoms. The physician may refer to these records whenever required.
Which medication classification is given to counteract extrapyramidal symptoms (EPS)?
- A. Antidepressants
- B. Antianxiety
- C. Anticholinergics
- D. Anticonvulsants
Correct Answer: C
Rationale: Anticholinergic drugs such as Artane and Cogentin are given to prevent or relieve EPS. Antidepressants, antianxiety, and anticonvulsant medications are not given to counteract EPS.
The nurse is caring for a client who has experienced readmission to the behavioral health unit for an exacerbation of schizophrenia. Which assessment question asked by the nurse identifies a possible cause for the return?
- A. Do you take a generic form of your medications?
- B. When was your last dose of medication?
- C. Are you having any side effects of the medication?
- D. Can you afford to purchase your medication?
Correct Answer: B
Rationale: The nurse is correct to identify that noncompliance with drug therapy is the leading cause of the return of disease symptoms and the need for short-term hospitalization. Asking when the client's last dose of medication was opens communication for when the medication was last administered. If it was not at the prescribed time, the conversation allows the nurse to probe why. Taking a generic medication does not change the effectiveness. Asking if the client can afford the medication or if the medication causes side effects does not directly address the question of noncompliance.
The nurse is discharging four clients from the behavioral health unit. Which client would be the best candidate for long-term inpatient care?
- A. The client experiencing hallucinations
- B. The client with feelings of persecution
- C. The client with a love interest
- D. The client with suspicion and anger
Correct Answer: D
Rationale: Once a client is in the mental health system, every effort is made to avoid institutionalization. The exception is when the client is dangerous to self and others. The nurse is most correct to anticipate the client with suspicion and anger to be the best candidate for long-term inpatient care. Clients who have hallucinations or feelings of persecution and those with a love interest being discharged from a behavioral health unit can be monitored in an outpatient setting.