Nursing Elites

1. An elderly client diagnosed with delirium is being treated with antipsychotic medication. Which side effect should the nurse monitor for in this client?

• A. Akathisia
• B. Hallucinations
• C. Orthostatic hypotension
• D. Drowsiness

Correct answer: C

Rationale: The correct side effect that the nurse should monitor for in an elderly client diagnosed with delirium and treated with antipsychotic medication is orthostatic hypotension. Antipsychotic medications can lead to a drop in blood pressure upon standing, particularly in elderly individuals. Akathisia (choice A) refers to a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, which can be a side effect of antipsychotic medications but is not specific to elderly clients with delirium. Hallucinations (choice B) are sensory perceptions that appear real but are created by the mind, and while they can be associated with certain conditions or medications, they are not a common side effect of antipsychotic medications in elderly clients with delirium. Drowsiness (choice D) is a general CNS depressant effect that can occur with antipsychotic medications but is not the specific side effect that the nurse should be monitoring for in this case.

2. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?

• A. Notify the healthcare provider immediately and prepare for administration of an antidote.
• B. Hold the medication and refrain from administering additional amounts of the drug.
• C. Record the symptoms as potential signs of lithium toxicity and hold further medication.
• D. Notify the healthcare provider of the symptoms for evaluation before the next administration of the drug.

Correct answer: A

Rationale: Diarrhea, vomiting, and drowsiness in a client being treated with lithium carbonate for bipolar disorder may indicate lithium toxicity. The nurse should promptly notify the healthcare provider to ensure immediate medical intervention. The correct action is to prepare for the administration of an antidote if necessary. Holding the medication (Choice B) without immediate intervention could delay necessary treatment. Recording the symptoms as potential signs of lithium toxicity (Choice C) is more appropriate than considering them as normal side effects but does not emphasize the urgency of immediate action. Notifying the healthcare provider before the next administration of the drug (Choice D) may delay urgent intervention required for lithium toxicity.

3. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.

• A. Hold his medication and contact his prescriber.
• B. Wipe him with a washcloth wet with cold water or alcohol.
• C. Administer a medication such as benztropine IM to correct this dystonic reaction.
• D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.

Correct answer: C

Rationale: The correct intervention is to administer a medication such as benztropine IM to correct this dystonic reaction. The presentation of stiffness, diaphoresis, inability to respond verbally, and vital sign changes suggest an acute dystonic reaction, which is an extrapyramidal side effect of antipsychotic medications like haloperidol. Benztropine is an anticholinergic medication commonly used to manage these acute dystonic reactions. Option A is incorrect because holding the medication without addressing the acute symptoms may lead to worsening of the condition. Option B is incorrect as wiping with cold water or alcohol does not address the underlying cause of the symptoms. Option D is incorrect because it mentions tardive dyskinesia, which is a different condition characterized by involuntary movements that occur with long-term antipsychotic use, not the acute dystonic reaction seen here.

4. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care?

• A. Implement behavior modification therapy.
• B. Initiate caloric and nutritional therapy.
• C. Evaluate the client for low self-esteem.
• D. Record daily weights and graph trends.

Correct answer: B

Rationale: Initiating caloric and nutritional therapy is the most important intervention for this client due to the significant weight loss and presenting symptoms of hypotension, tachycardia, irregular menses, and hair loss. This intervention aims to address the physical effects of malnutrition and support the client's overall health. Behavior modification therapy (Choice A) may be beneficial in the long term to address underlying issues, but addressing the immediate nutritional needs is a priority. Evaluating the client for low self-esteem (Choice C) is important for holistic care but addressing the physical health concerns takes precedence. Recording daily weights and graphing trends (Choice D) is essential for monitoring progress but does not address the urgent need for nutritional support in this acute situation.

5. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

• A. I am here because the police thought I was doing something wrong
• B. At least I hit the wall instead of hitting the psychiatric aide
• C. I want to be here because I know it is the best psychiatric facility
• D. Don’t believe everything my family tells you, I am not crazy

Correct answer: B

Rationale: The correct answer is B because the client is projecting their aggressive impulses onto an inanimate object, the wall, instead of accepting their own feelings. This statement reflects the defense mechanism of projection. Choice A is not projection; it is an explanation of why the client is there. Choice C indicates acceptance of the facility and does not involve projection. Choice D is a denial statement rather than projection.

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