Nokea
Which intervention should the nurse implement when caring for a patient demonstrating manic behavior? Select one that doesn't apply.
- A. Monitor the patient's vital signs frequently.
- B. Keep the patient distracted with group-oriented activities.
- C. Provide the patient with frequent milkshakes and protein drinks.
- D. Reduce the volume on the television and dim bright lights in the environment.
Correct Answer: B
Rationale: When caring for a patient demonstrating manic behavior, it is crucial to monitor vital signs frequently to ensure the patient's physical health is stable. Providing nutrition, such as milkshakes and protein drinks, is essential to meet the patient's dietary needs. Diminishing environmental stimuli by reducing the volume on the television and dimming bright lights can help create a calmer environment. However, keeping the patient distracted with group-oriented activities may not be the most appropriate intervention as it could potentially exacerbate the manic behavior by overstimulating the patient. Therefore, this choice is the one that doesn't apply in managing manic behavior effectively.
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Luc's family comes home one evening to find him extremely agitated, and they suspect he is in a full manic episode. The family calls emergency medical services. While one medic is talking with Luc and his family, the other medic is counting something on his desk. What is the medic most likely counting?
- A. Hypodermic needles
- B. Fast food wrappers
- C. Empty soda cans
- D. Energy drink containers
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select one that does not apply.
- A. Hold his medication and contact his prescriber.
- B. Wipe him with a washcloth wet with cold water or alcohol.
- C. Administer a medication such as benztropine IM to correct this dystonic reaction.
- D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.
Correct Answer: C
Rationale: The patient's symptoms, including stiffness, diaphoresis, inability to respond verbally, and vital sign abnormalities, are indicative of neuroleptic malignant syndrome (NMS), a serious and potentially life-threatening side effect of antipsychotic medications. Administering a medication such as benztropine intramuscularly is the priority to address the dystonic reaction associated with NMS. This intervention can help alleviate symptoms and prevent further complications. Holding the medication and contacting the prescriber may be necessary but addressing the acute symptoms takes precedence. Wiping the patient with a cold washcloth or alcohol would not address the underlying medical emergency. Reassuring the patient about tardive dyskinesia is irrelevant and not the immediate concern in this scenario.
Which behavior is consistent with therapeutic communication?
- A. Offering your opinion when asked to convey support.
- B. Summarizing the essence of the patient's comments in your own words.
- C. Interrupting periods of silence before they become awkward for the patient.
- D. Telling the patient they did well when you approve of their statements or actions.
Correct Answer: B
Rationale: Summarizing the essence of the patient's comments in your own words is a key aspect of therapeutic communication as it demonstrates active listening and understanding. It shows the patient that their words have been heard and understood, fostering a sense of validation and empathy. Offering opinions, interrupting silence, or giving approval may not always align with the principles of therapeutic communication, which focus on patient-centered interactions and empathetic responses.
Which intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia?
- A. Screening a group of males aged 15 to 25 for early symptoms.
- B. Forming a support group for females aged 25 to 35 with substance use issues.
- C. Providing coping skills information to a group aged 45 to 55.
- D. Educating parents of developmentally delayed 5- to 6-year-olds on early intervention importance.
Correct Answer: A
Rationale: Screening males aged 15 to 25 for early symptoms of schizophrenia is a well-chosen intervention as this age group is at a higher risk for developing the condition. Early identification can lead to timely treatment and better outcomes, making this intervention particularly effective in addressing the population at risk for schizophrenia.
Which activity is most appropriate for a child with ADHD?
- A. Reading an adventure novel
- B. Monopoly
- C. Checkers
- D. Tennis
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.