Nursing Elites

1. A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that doesn't apply.

• A. Tardive dyskinesia
• B. Muscle tension
• C. Orthostatic hypotension
• D. Hyperglycemia

Correct answer: B

Rationale: Side effects of antipsychotic medications commonly include tardive dyskinesia, orthostatic hypotension, and hyperglycemia. Muscle tension is not typically associated with antipsychotic medication use. Tardive dyskinesia is characterized by involuntary movements, orthostatic hypotension refers to a drop in blood pressure upon standing, and hyperglycemia indicates high blood sugar levels. Monitoring these side effects is crucial for early detection and management, but muscle tension is not a typical side effect of antipsychotic medications.

2. A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?

• A. You shouldn't worry about that. It's not real.
• B. I don't see any FBI agents, but it sounds like you're feeling frightened.
• C. Let's talk about something else to take your mind off of it.
• D. Why do you think the FBI is watching you?

Correct answer: B

Rationale: Validating the client's feelings without reinforcing the delusion is important. This response acknowledges the client's fear without agreeing with the delusion. It shows empathy and understanding towards the client's emotions while not validating the delusional belief.

3. During a mental status examination, which of the following components should not be included in the assessment?

• A. Appearance and behavior
• B. Giving advice
• C. Mood and affect
• D. Cognitive function

Correct answer: B

Rationale: During a mental status examination, components such as appearance and behavior, mood and affect, and cognitive function are assessed. Giving advice is not a component of a mental status examination as it focuses on evaluating the client's mental state rather than providing guidance or recommendations.

4. During a manic episode in bipolar disorder, which intervention is most appropriate for a patient?

• A. Encourage the patient to engage in group activities.
• B. Provide a structured and low-stimulus environment.
• C. Allow the patient to set their schedule.
• D. Engage the patient in high-energy physical activities.

Correct answer: B

Rationale: During a manic episode in bipolar disorder, individuals may experience heightened energy levels, impulsivity, and decreased need for sleep. Providing a structured and low-stimulus environment is crucial in managing manic episodes. This intervention helps reduce overstimulation and provides a calm and predictable setting, which can be beneficial in helping the patient regain control and stability. Group activities and high-energy physical activities may exacerbate the symptoms of mania by increasing stimulation and excitement. Allowing the patient to set their schedule may not provide the necessary structure needed during a manic episode, hence making it less appropriate.

5. Which of the following are potential side effects of electroconvulsive therapy (ECT)? Select one that does not apply.

• A. Short-term memory loss
• B. Headache
• C. Confusion
• D. Tardive dyskinesia

Correct answer: D

Rationale: Potential side effects of ECT include short-term memory loss, headache, confusion, and nausea. Tardive dyskinesia is not a side effect of ECT; it is associated with long-term use of antipsychotic medications, particularly antipsychotics that block dopamine receptors over time. ECT is primarily used for severe depression, bipolar disorder, and certain psychotic disorders. The other choices, short-term memory loss, headache, and confusion, are known side effects of ECT and are usually short-term and manageable.

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