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Which patient is at greatest risk for physical abuse by a family member?
- A. An 8-year-old who is mentally challenged and living with a foster family
- B. A 15-year-old who lives with a single parent in an inner city apartment complex
- C. A 30-year-old adult who shares a home with a homosexual partner
- D. A 79-year-old with chronic depression who lives with a grandchild
Correct Answer: D
Rationale: The correct answer is D because the 79-year-old with chronic depression who lives with a grandchild is vulnerable due to age, health condition, and dependency on the grandchild. Older adults with mental health issues are at a higher risk of abuse, especially when living with family members. The other choices are less likely to be at greatest risk for physical abuse. A, B, and C do not have the same level of vulnerability due to age, health condition, or dependency as the 79-year-old with chronic depression living with a grandchild.
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A client who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia developed tardive dyskinesia as evidenced by tongue thrusting and chewing motions. The physician discontinued the chlorpromazine and prescribed Seroquel (quetiapine). As a result of this change, the nurse should carefully monitor for:
- A. Development of pseudoparkinsonism
- B. Development of dystonic reactions
- C. Improvement in tardive dyskinesia
- D. Worsening of anticholinergic symptoms
Correct Answer: C
Rationale: The correct answer is C: Improvement in tardive dyskinesia. Tardive dyskinesia is a side effect of long-term antipsychotic use, such as chlorpromazine. Quetiapine (Seroquel) is a second-generation antipsychotic with a lower risk of causing tardive dyskinesia. By discontinuing chlorpromazine and switching to quetiapine, the client is less likely to experience worsening of tardive dyskinesia symptoms. Monitoring for improvement in tardive dyskinesia is essential in this situation.
Choices A, B, and D are incorrect:
A: Development of pseudoparkinsonism is less likely with quetiapine compared to first-generation antipsychotics like chlorpromazine.
B: Dystonic reactions are acute side effects and are not typically associated with switching to quetiapine.
D: Anticholinergic symptoms are not directly related to tardive dyskinesia
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
- A. Lithium (Lithobid).
- B. Buspirone (BuSpar).
- C. Risperidone (Risperdal).
- D. Fluphenazine (Prolixin)
Correct Answer: D
Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.
A woman has been severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, has no financial resources of her own, and has no job skills. Which would be the most important referral for the nurse to make?
- A. Community food cupboard
- B. Vocational counseling
- C. Law enforcement
- D. Safe house or shelter
Correct Answer: D
Rationale: The correct answer is D: Safe house or shelter. This option is the most important referral because the woman is in immediate danger and needs a safe place to stay away from her abusive husband. It prioritizes her safety and well-being. Referring her to a safe house can provide her with protection, resources, and support to help her escape the abusive situation.
Choice A (Community food cupboard) is incorrect as it does not address the woman's immediate safety needs. Choice B (Vocational counseling) is also not the most urgent referral in this situation as the woman's safety should be the priority. Choice C (Law enforcement) might be necessary in the long run, but the immediate concern is ensuring the woman's safety by referring her to a safe house or shelter.
A PET scan involves the injection of
- A. radioactive sugar
- B. iodine
- C. metal particles
- D. xenon gas
Correct Answer: A
Rationale: PET scans use radioactive glucose (sugar) to measure brain activity, aiding in diagnosing mental disorders.
A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:
- A. Gain 1 to 2 pounds.
- B. Exercise 1 hour daily.
- C. Take a laxative every 3 days.
- D. Weigh self accurately using balanced scales.
Correct Answer: A
Rationale: The correct answer is A: Gain 1 to 2 pounds. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). In anorexia nervosa, gaining weight is crucial for recovery. Weight gain indicates improved nutritional status and overall health. Option B is incorrect as excessive exercise can exacerbate the patient's condition. Option C is incorrect as laxative use is not a recommended treatment for anorexia nervosa. Option D is incorrect as self-weighing may lead to obsessive behavior in patients with eating disorders.