Nursing Elites

1. A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?

• A. Instruct the client to take deep breaths and relax.
• B. Assess the client for signs of akathisia.
• C. Encourage the client to engage in physical activity.
• D. Administer a PRN dose of lorazepam (Ativan).

Correct answer: B

Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.

2. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

• A. Dizziness when standing.
• B. Shuffling gait and hand tremors.
• C. Urinary retention.
• D. Fever of 102°F.

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

3. Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend a daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?

• A. Medication non-compliance.
• B. Number of bathroom facilities.
• C. Infection control.
• D. Acting out behaviors.

Correct answer: C

Rationale: The priority issue that the RN should address is infection control. The unsanitary conditions in the bathroom, with sputum on the walls, urine in the sink and on the floors, and the toilet clogged with tissue, paper towels, and feces, pose a significant health risk to all residents and staff. Addressing infection control is crucial to prevent the spread of diseases and ensure the well-being of everyone in the facility. Medication non-compliance is important but not the priority in this situation. The number of bathroom facilities, while relevant, is not the immediate concern when faced with unsanitary conditions. Acting out behaviors, though a valid concern in mental health settings, are not the priority when faced with such unsanitary and potentially infectious conditions.

4. A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the most therapeutic nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Schedule specific times for handwashing.
• C. Encourage the client to discuss the thoughts and feelings behind the behavior.
• D. Restrict the client's access to soap and water.

Correct answer: C

Rationale: Encouraging the client to discuss the thoughts and feelings behind the behavior is the most therapeutic nursing intervention for a client with OCD who excessively washes hands. This approach can help the client understand the underlying reasons for the behavior, address the associated anxiety, and work toward behavior modification. Choices A, allowing the behavior to continue, and D, restricting access to soap and water, do not address the root cause of the behavior and may exacerbate anxiety. Choice B, scheduling specific times for handwashing, does not address the underlying emotional factors contributing to the behavior and may not effectively reduce the client's anxiety.

5. A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects?

• A. If I eat too many fruits, I'll get constipated.
• B. I need to take the medicine with food to avoid nausea.
• C. I have to get up slowly so I don't get dizzy.
• D. Sometimes I have to push myself because I'm sleepy.

Correct answer: A

Rationale: Choice A reflects a need for further teaching as the client mistakenly believes that eating too many fruits causes constipation, showing a misunderstanding about dietary fiber's role in preventing constipation. Choices B, C, and D demonstrate accurate understanding of managing clozapine's adverse effects, such as taking it with food to avoid nausea, getting up slowly to prevent dizziness, and pushing oneself when feeling sleepy.

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