Nursing Elites

1. When a patient with schizophrenia is taking haloperidol, what is a priority assessment for the nurse?

• A. Assessing for signs of tardive dyskinesia
• B. Monitoring for signs of neuroleptic malignant syndrome
• C. Checking for signs of depression
• D. Monitoring for changes in appetite

Correct answer: B

Rationale: Monitoring for signs of neuroleptic malignant syndrome is crucial for patients taking haloperidol. Neuroleptic malignant syndrome is a rare but serious side effect that can occur with antipsychotic medications like haloperidol. It presents with symptoms such as high fever, unstable blood pressure, confusion, muscle rigidity, and autonomic dysfunction. Early detection and intervention are essential to prevent serious complications.

2. A healthcare professional is caring for a group of clients. Which of the following clients should the healthcare professional consider for referral to an assertive community treatment (ACT) group?

• A. A client in an acute care mental health facility who has fallen several times while running down the hallway
• B. A client who lives at home and keeps forgetting to come in for a scheduled monthly antipsychotic injection for schizophrenia
• C. A client in a day treatment program who reports increasing anxiety during group therapy
• D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months

Correct answer: B

Rationale: The client who lives at home and repeatedly forgets to come in for a scheduled monthly antipsychotic injection for schizophrenia should be considered for referral to an assertive community treatment (ACT) group. ACT teams provide intensive community-based treatment and support for individuals with severe mental illness who may have difficulty adhering to treatment on their own. Choices A, C, and D do not describe individuals with severe mental illness who have difficulty adhering to treatment or need intensive community-based support, which are the typical candidates for referral to an ACT group.

3. What is a priority intervention for a patient with severe anxiety?

• A. Encouraging the patient to discuss their feelings in detail.
• B. Providing a calm and quiet environment.
• C. Encouraging the patient to participate in group activities.
• D. Providing detailed information about their treatment plan.

Correct answer: B

Rationale: When dealing with a patient experiencing severe anxiety, providing a calm and quiet environment is a priority intervention. This approach helps reduce stimuli and anxiety levels, creating a more soothing atmosphere for the individual. Encouraging the patient to discuss their feelings in detail or participate in group activities may be beneficial in certain situations, but establishing a peaceful setting takes precedence when managing severe anxiety. Providing detailed information about their treatment plan, although important, may not be the immediate priority when the patient is in a state of severe anxiety and needs a calming environment first.

4. A patient with obsessive-compulsive disorder (OCD) frequently washes their hands. Which nursing intervention is most appropriate?

• A. Allow the patient to wash their hands, then gradually limit the time spent on this behavior.
• B. Discourage the patient from discussing their obsessions.
• C. Encourage the patient to suppress their compulsive behaviors.
• D. Avoid setting limits on the patient's compulsive behaviors.

Correct answer: A

Rationale: In managing a patient with OCD who frequently washes their hands, it is important to understand that compulsive behaviors provide temporary relief from anxiety. Allowing the patient to engage in their rituals initially and then gradually setting limits on the time spent can help them gain control over their compulsions. This approach supports the patient without causing undue distress, ultimately assisting in managing OCD symptoms effectively. Choice B is incorrect as discouraging the patient from discussing their obsessions can hinder therapeutic communication and understanding of their condition. Choice C is wrong because encouraging the patient to suppress their compulsive behaviors may increase their anxiety and lead to worsening symptoms. Choice D is also incorrect as avoiding setting limits on the patient's compulsive behaviors does not help the patient in gaining control over their OCD symptoms.

5. A patient with obsessive-compulsive disorder (OCD) is under the care of a nurse. Which intervention is most appropriate?

• A. Encourage the patient to suppress their compulsive behaviors.
• B. Allow the patient to perform their rituals, then gradually limit the time spent on these rituals.
• C. Discourage the patient from discussing their obsessions.
• D. Avoid setting limits on the patient’s compulsive behaviors.

Correct answer: B

Rationale: In managing a patient with OCD, it is crucial to allow them to perform their rituals while gradually limiting the time spent on these rituals. This approach helps the patient feel supported while working towards reducing the compulsive behaviors. Choice A is incorrect because suppressing compulsive behaviors can increase anxiety and distress. Choice C is inappropriate as discussing obsessions is part of therapy. Choice D is not recommended as setting limits on compulsive behaviors is essential for treatment.

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