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The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?
- A. Early diagnosis and treatment provide the only means for a cure of ASD.
- B. Early diagnosis and treatment gives your child the best chance of becoming a fully functioning adult.
- C. Early diagnosis and treatment provides the best way to ensure that your child can be admitted to an assisted living facility as an adult.
- D. Early diagnosis and treatment prevent your child from developing any other mental condition.
Correct Answer: B
Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills. Choice A is incorrect as there is currently no cure for ASD. Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility. Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.
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A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
- A. Tactile hallucinations
- B. Tardive dyskinesia
- C. Restlessness and muscle rigidity
- D. Reports of hearing disturbing voices
Correct Answer: C
Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms, such as restlessness and muscle rigidity, which are common side effects of antipsychotic medications like haloperidol. Tactile hallucinations and reports of hearing disturbing voices are symptoms of schizophrenia that would typically be addressed by the antipsychotic medication (haloperidol) itself. Tardive dyskinesia, a potential side effect of long-term antipsychotic use, would require discontinuation of the antipsychotic medication rather than administration of benztropine.
A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially the nurse should plan this for a manic client:
- A. Set realistic limits to the client's behavior
- B. Repeat verbal instructions as often as needed
- C. Allow the client to express feelings to relieve tension
- D. Assign staff to be with the client at all times to help maintain control
Correct Answer: A
Rationale: For a manic client who is hyperactive and may engage in injurious activities, setting realistic limits to the client's behavior is crucial to ensure safety. A quiet environment with firm and consistent limits helps in managing the client's behavior effectively. While repeating verbal instructions can be helpful due to the client's distractibility, it is not the priority compared to setting limits for safety concerns. Allowing the client to express feelings is important, but it should be done through non-destructive methods. Assigning staff to be with the client at all times is not realistic or feasible in the clinical setting and does not address the core issue of managing the client's behavior and ensuring safety.
The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?
- A. All elderly individuals experience depression occasionally.''
- B. I'm relieved that I will improve within 2 or 3 days.''
- C. I never realized depression could occur without a specific cause.''
- D. Reducing stress in my life will alleviate the depression.''
Correct Answer: C
Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching. Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding. Choice B is incorrect as it reflects a misconception about the quick resolution of depression. Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.
The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
- A. To tell the client this is not true; that we all have a purpose in life.
- B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
- C. To reassure the client that you know how the client is feeling and that things will get better.
- D. To identify recent behaviors or accomplishments that demonstrate skill ability.
Correct Answer: C
Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.
A client with a new prescription for lithium carbonate for bipolar disorder is being educated by a nurse on early indications of toxicity. The nurse should include which of the following manifestations in the teachings?
- A. Constipation
- B. Polyuria
- C. Rash
- D. Tinnitus
Correct Answer: B
Rationale: Polyuria is a crucial early indication of lithium toxicity. It results from the drug's effect on the kidneys, leading to increased urine output. This is a significant symptom to monitor as it can indicate potential toxicity. Constipation, rash, and tinnitus are not typically associated with early indications of lithium toxicity. Constipation is more commonly seen as a side effect of some medications, while rash and tinnitus are not specific indicators of lithium toxicity.