Nursing Elites

1. 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 one that does not 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 patient's symptoms, including stiffness, diaphoresis, inability to respond verbally, and vital sign abnormalities, are indicative of neuroleptic malignant syndrome (NMS), a serious and potentially life-threatening side effect of antipsychotic medications. Administering a medication such as benztropine intramuscularly is the priority to address the dystonic reaction associated with NMS. This intervention can help alleviate symptoms and prevent further complications. Holding the medication and contacting the prescriber may be necessary but addressing the acute symptoms takes precedence. Wiping the patient with a cold washcloth or alcohol would not address the underlying medical emergency. Reassuring the patient about tardive dyskinesia is irrelevant and not the immediate concern in this scenario.

2. A client is being taught relaxation techniques to manage anxiety. Which of the following techniques should not be included in the teaching? Select all that apply.

• A. Deep breathing exercises
• B. Progressive muscle relaxation
• C. Mindfulness meditation
• D. Cognitive restructuring

Correct answer: D

Rationale: Deep breathing exercises, progressive muscle relaxation, and mindfulness meditation are commonly used relaxation techniques to manage anxiety. Cognitive restructuring is a cognitive-behavioral technique aimed at changing negative thought patterns and beliefs, not a relaxation technique. It focuses on altering cognitive distortions rather than inducing physical relaxation responses.

3. A client with obsessive-compulsive disorder (OCD) spends several hours each day washing her hands. Which intervention should the nurse implement?

• A. Encourage the client to wash her hands less frequently.
• B. Set a time limit for hand washing.
• C. Teach the client relaxation techniques.
• D. Discourage the client from washing her hands.

Correct answer: B

Rationale: Setting a time limit for hand washing is an appropriate intervention for a client with OCD who spends excessive time on this compulsive behavior. By setting a time limit, the nurse can help the client gradually reduce the compulsive behavior, promoting a more manageable approach to hand washing without completely discouraging it. Encouraging the client to wash her hands less frequently (Choice A) may not address the root of the issue and could lead to increased anxiety. Teaching relaxation techniques (Choice C) may be helpful for overall anxiety management but may not directly address the excessive hand washing behavior. Discouraging the client from washing her hands (Choice D) may increase anxiety and resistance, making it a less effective intervention.

4. A client is being assessed by a nurse after being diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?

• A. Weight gain and increased appetite
• B. Lanugo on the face and back
• C. Increased body temperature and tachycardia
• D. Hyperactivity and distractibility

Correct answer: B

Rationale: In anorexia nervosa, individuals often develop lanugo, fine soft hair, on the face and back. This is a physiological response to the body's attempt to conserve heat due to a lack of subcutaneous fat. It is a common physical finding in clients with anorexia nervosa and can be a sign of severe malnutrition. Choices A, C, and D are incorrect because weight gain and increased appetite, increased body temperature and tachycardia, and hyperactivity and distractibility are not typically associated with anorexia nervosa. In fact, weight loss, decreased appetite, hypothermia, and bradycardia are more commonly seen in individuals with anorexia nervosa.

5. During an acute panic attack, which intervention should the nurse implement?

• A. Encourage the client to discuss their feelings
• B. Provide a calm environment
• C. Teach the client deep breathing exercises
• D. Leave the client alone to calm down

Correct answer: C

Rationale: During an acute panic attack, the priority intervention is to create a calm and safe environment. Teaching the client deep breathing exercises is crucial as it promotes relaxation and reduces hyperventilation, helping to manage the panic attack effectively. Encouraging the client to discuss their feelings may exacerbate the panic by increasing emotional distress. Providing a busy environment can escalate stress levels rather than alleviate them. Leaving the client alone may lead to feelings of abandonment or worsen the panic attack. Therefore, the most appropriate intervention is to teach deep breathing exercises to help the client regain control and manage the panic attack.

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