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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.
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A patient with schizophrenia has received typical (first-generation) antipsychotics for a year. His hallucinations are less intrusive, but he remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might consult the prescribing health care provider to suggest a change to:
- A. Haloperidol (Haldol).
- B. Olanzapine (Zyprexa).
- C. Diphenhydramine (Benadryl).
- D. Chlorpromazine (Thorazine).
Correct Answer: B
Rationale: The correct answer is B: Olanzapine (Zyprexa). Olanzapine is an atypical (second-generation) antipsychotic that has been shown to effectively target negative symptoms of schizophrenia, such as apathy, poverty of thought, and social isolation. It also helps with mood stabilization and cognitive function, which can improve the patient's ability to work and engage in social interactions.
Choice A: Haloperidol (Haldol) is a typical (first-generation) antipsychotic like the current medication, which is less effective in treating negative symptoms and can potentially worsen them.
Choice C: Diphenhydramine (Benadryl) is an antihistamine and not indicated for treating schizophrenia symptoms.
Choice D: Chlorpromazine (Thorazine) is another typical (first-generation) antipsychotic, similar to the current medication, and may not adequately address the negative symptoms the patient is experiencing.
The nurse is caring for a client who is being treated for comorbid eating or affective disorder. For which medication would the nurse expect to prepare a client teaching plan?
- A. Fluoxetine (Prozac).
- B. Diazepam (Valium).
- C. Lorazepam (Ativan).
- D. Lithium.
Correct Answer: A
Rationale: The correct answer is A: Fluoxetine (Prozac). Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat eating disorders and affective disorders like depression. The nurse would prepare a client teaching plan for fluoxetine to educate the client on its mechanism of action, potential side effects, proper dosing, and the importance of compliance. Diazepam and lorazepam are benzodiazepines used for anxiety and not typically indicated for eating or affective disorders. Lithium is primarily used for bipolar disorder and not specifically for eating or affective disorders.
Which complication should a nurse monitor for when treating a patient with bulimia nervosa who is experiencing frequent vomiting?
- A. Hypokalemia and dental enamel erosion.
- B. Hyperkalemia and elevated blood pressure.
- C. Severe dehydration and low blood sugar.
- D. Hypercalcemia and weight gain.
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia and dental enamel erosion.
1. Bulimia nervosa involves frequent vomiting, leading to loss of potassium (hypokalemia) due to electrolyte imbalance.
2. Vomiting also damages tooth enamel, causing dental erosion.
3. Hyperkalemia and elevated blood pressure (choice B) are not typically associated with bulimia.
4. Severe dehydration and low blood sugar (choice C) are possible but not the primary concerns.
5. Hypercalcemia and weight gain (choice D) are not common complications of bulimia.
A patient has a maladaptive response to eating regulation. Findings include the following: height, 5 feet 3 inches; current weight, 80 pounds with weight loss of 30% of body weight over the past 3 months; T, 96.6m F; BP, 68/40; P, 40; R, 20; poor skin turgor; lanugo; amenorrhea of 6 months' duration; admits to restricting intake to 350 calories daily; is a vegetarian; dissatisfied with eating pattern as evidenced by patient statement, 'I need to lose another 10 pounds to be at ideal weight'; diagnostic testing reveals serum potassium of 2.9 mEq/L and urine specific gravity of 1.028. Which of the following would be the highest priority nursing diagnosis for this patient?
- A. Imbalanced nutrition, less than body requirements.
- B. Disturbed body image.
- C. Deficient fluid volume.
- D. Powerlessness.
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume. The patient is displaying signs of severe malnutrition and dehydration, as evidenced by significant weight loss, low blood pressure, low heart rate, and poor skin turgor. The low serum potassium and high urine specific gravity indicate dehydration. Addressing fluid volume deficiency is the top priority to stabilize the patient's condition and prevent further complications like electrolyte imbalances and organ damage. Choices A and B are important but secondary to addressing the immediate threat of dehydration. Choice D is not the priority as the patient's primary concern is physiological rather than psychological.
A client experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the client to employ when the voices are troublesome?
- A. Take additional antipsychotic medication
- B. Lie down in bed and try to sleep
- C. Sing or whistle to compete with the voices
- D. Eat a large portion of chocolate
Correct Answer: C
Rationale: The correct answer is C: Sing or whistle to compete with the voices. This technique is effective as it can help distract the client from the intrusive auditory hallucinations. By engaging in singing or whistling, the client can shift their focus away from the voices, making them less bothersome. This method can also empower the client by giving them a sense of control over the situation.
Other choices are incorrect:
A: Taking additional antipsychotic medication may not be necessary in this situation and should be prescribed by a healthcare provider.
B: Lying down and trying to sleep may not address the immediate distress caused by the hallucinations.
D: Eating a large portion of chocolate is not a valid behavioral technique for managing auditory hallucinations.