Nursing Elites

1. The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention?

• A. Very high temperature
• B. Muscular rigidity
• C. Tremors
• D. Altered consciousness

Correct answer: A

Rationale: A very high temperature is a hallmark symptom of Neuroleptic Malignant Syndrome (NMS), which is a rare but potentially life-threatening side effect of antipsychotic medications. This symptom is uniquely indicative of NMS and requires immediate medical attention. Muscular rigidity, tremors, and altered consciousness can be seen in other conditions but are not as specifically linked to NMS as a very high temperature.

2. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

• A. Assign the client to a teen support group.
• B. Assess intake and output.
• C. Monitor for wheezing and apnea.
• D. Limit visitors to family members only.

Correct answer: B

Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.

3. 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.

4. A client with obsessive-compulsive disorder (OCD) repeatedly washes her hands throughout the day. What is the most therapeutic nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to talk about the underlying fears.
• C. Restrict the client's access to soap and water.
• D. Schedule a time for the client to perform the ritual.

Correct answer: B

Rationale: Encouraging the client to talk about the underlying fears is the most therapeutic nursing intervention for a client with OCD who repeatedly washes her hands. By discussing the fears, the client can gain insight into the behavior and work towards reducing the compulsion. Choice A is incorrect as allowing the client to continue the behavior can perpetuate the OCD symptoms. Choice C is incorrect as restricting access to soap and water can lead to increased anxiety and distress. Choice D is incorrect as scheduling a time for the client to perform the ritual does not address the underlying fears driving the behavior.

5. Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?

• A. Signs and symptoms of extrapyramidal effects (EPS).
• B. Information about substance abuse and schizophrenia.
• C. The effects of alcohol and drug interaction.
• D. The availability of support groups for those with dual diagnoses.

Correct answer: C

Rationale: Teaching about the effects of alcohol and drug interaction is crucial to prevent adverse reactions, especially with the long-acting injectable form of fluphenazine. Understanding how alcohol and drugs can interact with the medication will help the client and family to ensure medication effectiveness and avoid potential harmful effects. Choices A, B, and D are not the most important to teach in this scenario. While knowing the signs and symptoms of extrapyramidal effects (EPS) is important, understanding the effects of alcohol and drug interaction is more critical in this specific situation. Information about substance abuse and schizophrenia, as well as the availability of support groups, are essential aspects of care but are not the primary focus when switching to a long-acting injectable medication due to non-compliance.

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