Nokea
The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
- A. You appear to be speaking with someone
- B. Let's talk about the next time this happens
- C. You need to be calm and focus on something else
- D. The voices you are hearing are not real
Correct Answer: A
Rationale: This comment acknowledges the client's behavior without judgment, validating their experience and encouraging further discussion. Focusing on the future, redirecting, or denying the voices may not be therapeutic and could invalidate the client's reality.
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Following involvement in a motor vehicle collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
- A. Prochlorperazine 5 mg IM
- B. Hydromorphone 2 mg IM
- C. Lorazepam 2 mg IM
- D. Chlorpromazine 50 mg IM
Correct Answer: C
Rationale: Lorazepam is a benzodiazepine used to manage delirium tremens (DTs), a severe form of alcohol withdrawal, by reducing agitation and preventing seizures. Prochlorperazine and chlorpromazine are antipsychotics, not first-line for DTs. Hydromorphone is an opioid and inappropriate for DTs management.
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Administer the prescribed anticholinergic benztropine for dystonia
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms
- C. Direct the client to occupational therapy to distract him from somatic complaints
- D. Medicate the client with the prescribed antipsychotic thioridazine
Correct Answer: A
Rationale: The client's laterally contracted position and perception of contortion suggest acute dystonia, a side effect of risperidone. Benztropine, an anticholinergic, alleviates dystonia. Hot packs, occupational therapy, or thioridazine do not address this acute reaction.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A middle-aged man who is complaining of shortness of breath and is diaphoretic
- B. A young woman who suddenly goes blind with no indication of organic pathology
- C. An older adult who continuously complains of a headache and back pain
- D. An adolescent who becomes extremely anxious about going outside
Correct Answer: B
Rationale: Sudden blindness with no organic pathology suggests a functional neurological symptom disorder, which falls under conversion disorder. Shortness of breath and diaphoresis may indicate a medical condition or panic attack. Headaches and back pain could have various causes. Anxiety about going outside suggests agoraphobia or another anxiety disorder.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation
- C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed
- D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm
Correct Answer: A
Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.