Nursing Elites

1. A client is being treated with a tricyclic antidepressant (TCA). Which side effect should the nurse monitor for?

• A. Constipation and urinary retention.
• B. Increased appetite and weight loss.
• C. Sedation and blurred vision.
• D. Insomnia and dry mouth.

Correct answer: A

Rationale: The correct answer is A: Constipation and urinary retention. Tricyclic antidepressants (TCAs) are known to have anticholinergic side effects, which include constipation and urinary retention. These side effects occur due to the inhibition of cholinergic receptors, leading to decreased gastrointestinal motility and relaxation of the detrusor muscle in the bladder. Choices B, C, and D are incorrect because increased appetite, weight loss, sedation, blurred vision, insomnia, and dry mouth are not typically associated with the use of TCAs. Monitoring for constipation and urinary retention is essential to prevent complications and ensure the client's safety.

2. A client with schizophrenia is being discharged home after an extended stay in a psychiatric hospital. Which statement by the client indicates that further teaching about medication management is needed?

• A. “I will take my medication only when I feel like it.”
• B. “I need to follow up with my psychiatrist regularly.”
• C. “I will notify my healthcare provider if I experience side effects.”
• D. “I should avoid alcohol while on my medication.”

Correct answer: A

Rationale: The correct answer is A. This statement indicates a lack of understanding about medication management for schizophrenia. Medications for schizophrenia should be taken consistently as prescribed for optimal effectiveness, regardless of how the client feels. Choice B is a correct statement as regular follow-up with a psychiatrist is important for monitoring progress and adjusting treatment. Choice C demonstrates good awareness of potential side effects and the need for communication with healthcare providers. Choice D reflects appropriate knowledge as alcohol can interact with medications and may reduce their effectiveness.

3. The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?

• A. Completely abstain from heroin or cocaine use.
• B. Remain alcohol-free for 12 hours prior to the first dose.
• C. Attend monthly meetings of Alcoholics Anonymous.
• D. Admit to others that he is a substance user.

Correct answer: B

Rationale: The correct answer is B: "Remain alcohol-free for 12 hours prior to the first dose." It is essential for the client to understand the importance of abstaining from alcohol for at least 12 hours before starting disulfiram to prevent potential adverse reactions. Choice A is incorrect because disulfiram is specifically used to deter alcohol consumption, not heroin or cocaine use. Choice C is not directly related to the initiation of disulfiram therapy and attending AA meetings is not a requirement for taking disulfiram. Choice D is irrelevant and unnecessary for the initiation of disulfiram therapy.

4. A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages.
• B. Ask the client’s husband to interpret the discrepancy.
• C. Ignore the nonverbal behavior and focus on the client’s verbal messages.
• D. Integrate the verbal and nonverbal messages and interpret them as one.

Correct answer: A

Rationale: When a nurse observes a discrepancy between a client's verbal and nonverbal communication, it is essential to pay close attention and document the nonverbal messages. Nonverbal cues, such as body language and facial expressions, can provide valuable insights into the client's emotional state, feelings, and concerns that may not be expressed verbally. By documenting these nonverbal messages, the nurse can gain a more comprehensive understanding of the client's communication and address any potential underlying issues. Asking the client's husband to interpret the discrepancy (Choice B) may not always provide an accurate understanding of the client's nonverbal cues. Ignoring the nonverbal behavior (Choice C) could lead to missing important cues affecting the client's care. Integrating verbal and nonverbal messages (Choice D) is important, but initially focusing on documenting and understanding the nonverbal cues can enhance the nurse's assessment and communication with the client.

5. What intervention is best for the nurse to implement for a male client with schizophrenia who is demonstrating echolalia, which is becoming annoying to other clients on the unit?

• A. Avoid acknowledging the behavior.
• B. Isolate the client from other clients.
• C. Administer a PRN sedative.
• D. Escort the client to his room.

Correct answer: D

Rationale: Echolalia, the constant repetition of what others are saying, can be disruptive to the therapeutic environment. The most appropriate intervention is to escort the client to his room. This action provides the client with a private space where he can engage in the behavior without disturbing other clients. Avoiding acknowledgment of the behavior (Choice A) may not address the issue and could lead to increased annoyance among other clients. Isolating the client (Choice B) may have negative psychological effects and should be avoided unless absolutely necessary for safety concerns. Administering a PRN sedative (Choice C) should be considered only as a last resort and if other de-escalation techniques have been unsuccessful.

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