Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction:
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Solution
Neuroleptic malignant syndrome.
Option C: The client’s signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment.
Option A: Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles.
Option B: Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles.
Option D: Akathisia causes restlessness, anxiety, and jitteriness.
Which information is most important for the nurse Trinity to include in a teaching plan for a male schizophrenic client taking clozapine (Clozaril)?
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Solution
Report a sore throat or fever to the physician immediately.
Option B: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine.
Option A: Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/μl, the medication must be stopped.
Option C: Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension.
Option D: The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician.
Nurse Maureen knows that the non-antipsychotic medication used to treat some clients with schizoaffective disorder is:
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Solution
lithium carbonate (Lithane)
Option C: Lithium carbonate, an antimanic drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including manic-like activity. Lithium helps control the affective component of this disorder.
Option A: Phenelzine is a monoamine oxidase inhibitor prescribed for clients who don’t respond to other antidepressant drugs such as imipramine.
Option B: Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients.
Option D: Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and that undergoing cocaine detoxification.
David with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?
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Solution
“Your cursing is interrupting the activity. Take time out in your room for 10 minutes.”
Option C: The nurse should set limits on client behavior to ensure a comfortable environment for all clients.
Option A: The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended.
Option B: This is incorrect because it implies that the client’s actions reflect feelings toward the staff instead of the client’s own misery.
Option D: Judgmental remarks may decrease the client’s self-esteem.
Nurse Judy knows that statistics show that in adolescent suicidal behavior:
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Solution
Males are more likely to use lethal methods than are females
Option D: This finding is supported by research; females account for 90% of suicide attempts but males are three times more successful because of methods used.
Nurse John is aware that most crisis situations should resolve in about:
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Solution
4 to 6 weeks
Option B: Crisis is self-limiting and lasts from 4 to 6 weeks.
Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the tricyclic antidepressants. After teaching the client about the medication, Nurse Marian evaluates that learning has occurred when the client states, “I will avoid:
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Solution
Chocolate milk, aged cheese, and yogurt’”
Option B: These high-tyramine foods, when ingested in the presence of an MAO inhibitor, cause a severe hypertensive response.
When establishing an initial nurse-client relationship, Nurse Hazel should explore with the client the:
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Solution
Client’s perception of the presenting problem.
Option A: The nurse can be most therapeutic by starting where the client is, because it is the client’s concept of the problem that serves as the starting point of the relationship.
Nurse Mylene recognizes that the most important factor necessary for the establishment of trust in a critical care area is:
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Solution
Presence
Option D: The constant presence of a nurse provides emotional support because the client knows that someone is attentive and available in case of an emergency.
The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client. Nurse Katrina would be aware that the teaching about the side effects of this drug were understood when the client state, “I will call my doctor immediately if I notice any:
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Solution
Fine hand tremors or slurred speech
Option B: These are common side effects of lithium carbonate.