Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:
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Solution
Take the client’s blood pressure
Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client’s blood pressure (lying, sitting, and standing) before administering this drug.
Option A: If the client had taken the drug previously, the nurse would also need to assess the skin color and sclera for signs of jaundice, a possible drug side affect; however, based on the information given here, there is no evidence that the client has received chlorpromazine before.
Option D: Although the drug can cause urine retention, asking the client to avoid will not alter this anticholinergic effect.
A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages?
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Solution
Aged cheese and red wine
Aged cheese and red wines contain the substance tyramine which, when taken with an MAOI, can precipitate a hypertensive crisis.
Options B, C, and D: The other foods and beverages do not contain significant amounts of tyramine and, therefore, are not restricted.
When providing family therapy, the nurse analyzes the functioning of healthy family systems. Which situations would not increase stress on a healthy family system?
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Solution
Parental disagreement
In a functional family, parents typically do not agree on all issues and problems. Open discussion of thoughts and feeling is healthy, and parental disagreement should not cause system stress.
Options A, B, and C: The remaining answer choices are life transitions that are expected to increase family stress.
The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity?
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Solution
Diuretics
The use of diuretics would cause sodium and water excretion, which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium.
Options A, B, and D: Concurrent use of any of the remaining medications will not increase the risk of lithium toxicity.
Group members have worked very hard, and the nurse reminds them that termination is approaching. Termination is considered successful if group members:
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Solution
Decide to continue.
As the group progresses into the working phase, group members assume more responsibility for the group. The leader becomes more of a facilitator. Comments about behavior in a group are indicators that the group is active and involved.
Options B, C, and D: The remaining answer choices would indicate the group progress has not advanced to the working phase.
Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in?
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Solution
Initiation phase
Increased anxiety and uncertainty characterize the initiation phase in group therapy. Group members are more self-reliant during the working and termination phases.
The nurse considers a client’s response to crisis intervention successful if the client:
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Solution
Returns to his previous level of functioning.
Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning.
Options A, B, and C: The remaining answer choices are not considered the primary outcome of crisis intervention, although they may occur as a side benefit.
Which factors are the most essential for the nurse to assess when providing crisis intervention foer a client?
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Solution
The client’s perception of the triggering event and availability of situational supports
The most important factors to determine in this situations are the client’s perception of the crisis event and the availability of support (including family and friends) to provide basic needs.
Options A, B, and D: Although the nurse should assess the other factors, they are not as essential as determining why the client considers this a crisis and whether he can meet his present needs.
Which neurotransmitter has been implicated in the development of Alzheimer’s disease?
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Solution
Acetylcholine
A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimer’s disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimer’s disease.
Which nursing intervention is most appropriate for a client with Alzheimer’s disease who has frequent episodes emotional lability?
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Solution
Reduce environmental stimuli to redirect the client’s attention.
The client with Alzheimer’s disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client’s attention.
Option A: The client with Alzheimer’s disease loses the cognitive ability to respond to either humor or logic.
Option B: An over stimulating environment may cause the labile mood, which will be difficult for the client to understand.
Option D: The client lacks any insight into his or her own behavior and therefore will be unaware of any causative factors.