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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.
- B. Lithium.
- C. Benztropine.
- D. Magnesium.
Correct Answer: C
Rationale: Benztropine is used to manage extrapyramidal symptoms associated with antipsychotics, so it should be discontinued if the antipsychotic is stopped.
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A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)
- A. Decreased prothrombin time and partial thromboplastin levels.
- B. Increased values of serum levels for liver function profile.
- C. Increasingly larger amounts of alcohol are needed to feel drunk.
- D. Periodic indigestion with negative occult blood in stool.
- E. Memory lapses of events that occurred when drinking.
Correct Answer: B,C,D,E
Rationale: Increased liver function profile values, tolerance to alcohol, indigestion, and memory lapses are common in chronic alcohol dependency, reflecting liver damage, tolerance, gastrointestinal issues, and blackouts.
During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn't I use it? Which response is best for the nurse to provide?
- A. Marijuana is a highly addictive substance.
- B. Altering one's ability to think clearly places self and others at risk.
- C. Healthcare providers sometimes prescribe marijuana to control nausea.
- D. Drug use has moral implications that should be discussed with parents.
Correct Answer: B
Rationale: This response highlights the immediate risk of impaired thinking, emphasizing potential harm to self and others from marijuana use.
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?
- A. The healthcare provider's history and physical.
- B. Recent urine drug testing (UDT) results.
- C. Baseline nursing admission assessment.
- D. Abnormal Involuntary Movement Scale (AIMS).
Correct Answer: D
Rationale: The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool for these symptoms.
A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?
- A. Help the client identify thoughts that may be triggers.
- B. Explore past behaviors that have provided relief.
- C. Attempt to distract to another focus or activity.
- D. Speak calmly to the client stating assurance of safety.
Correct Answer: D
Rationale: Speaking calmly and providing assurance of safety is the first step in managing severe anxiety, helping to stabilize the client.
An adult client presents to the community mental health center accompanied by the client's spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?
- A. Sleep deprivation related to state of hyperactivity.
- B. Ineffective coping related to biochemical changes.
- C. Risk for self-directed violence related to impulsive behavior.
- D. Imbalanced nutrition related to caloric expenditure.
Correct Answer: C
Rationale: The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority due to potential immediate harm.