Nursing Elites

1. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?

• A. Place the client on seizure precautions and monitor her frequently.
• B. Take the client's vital signs and notify the physician immediately.
• C. Describe the symptoms to the charge nurse and document them in the client's record.
• D. No action is required at this time as these are known side effects of her medications.

Correct answer: B

Rationale: The correct action for the nurse to initiate is to take the client's vital signs and notify the physician immediately. These symptoms may indicate neuroleptic malignant syndrome, a rare but life-threatening reaction to antipsychotic medications, requiring immediate medical attention. Placing the client on seizure precautions and monitoring her frequently (Choice A) is not the most appropriate action in this situation. Describing the symptoms to the charge nurse and documenting them in the client's record (Choice C) delays prompt medical intervention. Choosing not to take any action (Choice D) is dangerous as the symptoms described suggest a serious condition that needs urgent evaluation and treatment.

2. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

• A. Did you really believe you were Jesus Christ?
• B. I think you're getting well.
• C. Others have had similar thoughts when under stress.
• D. Why did you think you were Jesus Christ?

Correct answer: C

Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.

3. A client with generalized anxiety disorder (GAD) is prescribed alprazolam (Xanax). What is the most important teaching point for the nurse to include?

• A. Take this medication at the first sign of anxiety.
• B. Do not stop taking this medication abruptly.
• C. You may experience weight gain while taking this medication.
• D. This medication may cause vivid dreams.

Correct answer: B

Rationale: The most important teaching point for a client prescribed alprazolam is not to stop taking the medication abruptly. Abruptly stopping alprazolam, a benzodiazepine, can lead to withdrawal symptoms. It is crucial to taper off the medication under medical supervision to prevent adverse effects. Choice A is incorrect because taking the medication at the first sign of anxiety is not the key teaching point. Choice C is incorrect because weight gain is not a common side effect of alprazolam. Choice D is incorrect because vivid dreams are not a significant concern compared to the risks of abrupt discontinuation of the medication.

4. What is the best initial action for the nurse to take with a manic depressive male client who becomes loud and verbally aggressive towards a nurse?

• A. Have the staff escort the client to his room.
• B. Tell the client that his behavior will be recorded in his record.
• C. Redirect the client by asking him to engage in a game with peers.
• D. Review the medication record for an antipsychotic drug.

Correct answer: C

Rationale: In dealing with a manic depressive client who is being verbally aggressive, the best initial action for the nurse is to redirect the client by engaging him in a more constructive activity, such as playing card games with peers. This approach can help de-escalate the situation, shift the client's focus positively, and provide a distraction from the current behavior. Having the staff escort the client to his room may escalate the situation further. Threatening to record the behavior in his record is not likely to be effective in managing the immediate situation. Reviewing the medication record for an antipsychotic drug is important but would not be the best initial action in this scenario when the client is being verbally aggressive.

5. A client is diagnosed with schizophrenia and exhibits apathy, lack of energy, and lack of interest in daily activities. The nurse should recognize that these symptoms are most likely due to which of the following?

• A. Negative symptoms of schizophrenia.
• B. Positive symptoms of schizophrenia.
• C. Side effects of antipsychotic medication.
• D. Symptoms of depression.

Correct answer: A

Rationale: Apathy, lack of energy, and lack of interest in daily activities are negative symptoms of schizophrenia (A). Positive symptoms of schizophrenia include hallucinations and delusions (B). While antipsychotic medication side effects can sometimes cause lethargy or sedation (C), the scenario specifically describes negative symptoms. Depression can also cause similar symptoms (D), but in the context of schizophrenia, these are recognized as negative symptoms.

Similar Questions