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The nurse notes that a male client, who is taking an antipsychotic medication, is constantly moving from chair to chair during a group activity, and he complains that he feels 'nervous and jittery inside.' The nurse is aware that this client most likely is experiencing:
- A. Akinesia
- B. Dystonia
- C. Dyskinesia
- D. Akathisia
Correct Answer: D
Rationale: The correct answer is D: Akathisia. Akathisia is a common side effect of antipsychotic medications characterized by restlessness, inability to sit still, and a feeling of inner restlessness or jitteriness. In this case, the client's constant movement and feeling of nervousness align with the symptoms of akathisia.
A: Akinesia is the opposite of what the client is experiencing, characterized by a lack of movement or muscle weakness.
B: Dystonia involves involuntary muscle contractions and abnormal postures, not constant movement.
C: Dyskinesia refers to abnormal, involuntary movements of the face, trunk, and limbs, which are not described in the scenario.
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Sleep disorders that are characterized by abnormal behavioral or physical events during sleep are called:
- A. insomnia.
- B. dyssomnias.
- C. hypersomnia.
- D. parasomnias.
Correct Answer: D
Rationale: The correct answer is D: parasomnias. Parasomnias are sleep disorders involving abnormal behaviors or physical events during sleep, such as sleepwalking or night terrors. This is the correct choice because it specifically addresses the description provided in the question.
A: Insomnia is characterized by difficulty falling or staying asleep, not abnormal behaviors during sleep.
B: Dyssomnias are a broad category of sleep disorders affecting the timing, quality, or amount of sleep, not necessarily involving abnormal behaviors during sleep.
C: Hypersomnia is a sleep disorder characterized by excessive daytime sleepiness, not abnormal behaviors during sleep.
In summary, the other choices do not align with the description of sleep disorders involving abnormal behavioral or physical events during sleep, making D the correct answer.
Many individuals with intellectual disabilities are conscientious and valued workers employed in which of the normal work environments. Individuals with more specific needs may need to pursue employment within:
- A. Sheltered accommodation
- B. Special workshops
- C. Sheltered workshops
- D. Special accommodation
Correct Answer: C
Rationale: Sheltered Workshops: Employment settings tailored to the needs and abilities of individuals with intellectual disabilities.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
Which situation would be most likely to serve as a trigger to a catastrophic reaction in a client with stage 2 Alzheimer's disease?
- A. Participating in singing 'Happy Birthday' to another client at dinner
- B. Being scolded by an aide for spilling a glass of milk
- C. Listening to Big Band music from the 1940s
- D. Eating cupcakes in the activities room
Correct Answer: B
Rationale: The correct answer is B because being scolded for spilling milk can trigger feelings of shame, embarrassment, and confusion in a person with Alzheimer's stage 2. This negative interaction can lead to heightened agitation, aggression, or emotional distress due to the client's impaired ability to process and regulate emotions. In contrast, choices A, C, and D involve positive or neutral activities that are less likely to evoke such strong negative emotions or reactions in someone with Alzheimer's disease.
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
- A. agranulocytosis"¦check the patient's complete blood count for changes
- B. tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale
- C. Tourette's syndrome"¦consult the patient's physician about a neuro evaluation
- D. anticholinergic effects"¦consult the physician about possible medication changes
Correct Answer: B
Rationale: Step 1: The patient is showing signs of abnormal movements like lip smacking, grimacing, and snakelike motions, which are indicative of tardive dyskinesia (TD).
Step 2: TD is a side effect of long-term antipsychotic use, such as fluphenazine decanoate.
Step 3: The Abnormal Involuntary Movement Scale is a validated tool to assess the severity of TD.
Step 4: Administering the Abnormal Involuntary Movement Scale will help confirm the diagnosis of TD.
Step 5: Prompt recognition of TD is crucial as it may be irreversible and can worsen over time if not addressed.
Summary:
- A: Agranulocytosis is a condition characterized by low white blood cell count, not related to the patient's symptoms.
- C: Tourette's syndrome presents with different symptoms and requires specialized evaluation.
- D: Anticholinergic effects do not typically manifest as the described