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 has been diagnosed with histrionic personality disorder. Which of the following behaviors should the nurse expect?

• A. Attention-seeking behavior
• B. Dramatic expressions of emotion
• C. Seductive behavior
• D. Dependency on others

Correct answer: A

Rationale: Individuals with histrionic personality disorder often display attention-seeking behaviors as a way to draw focus and validation from others. This behavior may manifest as exaggerated emotions and dramatic expressions to maintain the spotlight. While seductive behavior and dependency on others are potential characteristics of histrionic personality disorder, attention-seeking behavior is the hallmark trait. Therefore, the correct answer is attention-seeking behavior (Choice A). Dramatic expressions of emotion (Choice B) can be a feature of histrionic personality disorder, but it is not as characteristic as attention-seeking behavior. Seductive behavior (Choice C) may also be present in individuals with histrionic personality disorder, but it is not the primary behavior to expect. Dependency on others (Choice D) is not a core feature of histrionic personality disorder, although individuals with this disorder may seek attention and validation from others.

3. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

• A. Agree with the client's delusions to avoid confrontation.
• B. Challenge the client's delusions directly.
• C. Encourage the client to discuss their delusions in detail.
• D. Present reality and offer reassurance without reinforcing the delusions.

Correct answer: D

Rationale: When caring for a client with schizophrenia experiencing delusions, the nurse should present reality and offer reassurance without reinforcing the client's delusions. This approach helps the client maintain a connection to reality while feeling supported. Agreeing with the delusions may perpetuate false beliefs, while directly challenging them can lead to increased distress for the client. Encouraging the client to discuss their delusions in detail may further exacerbate their symptoms or reinforce their false beliefs. Therefore, the most therapeutic intervention is to gently present reality and provide reassurance to the client.

4. When assessing a client diagnosed with post-traumatic stress disorder (PTSD), which finding should the nurse expect?

• A. Hypervigilance
• B. Insomnia
• C. Flashbacks
• D. Suicidal ideation

Correct answer: A

Rationale: Clients with PTSD commonly exhibit symptoms such as hypervigilance, insomnia, flashbacks, difficulty concentrating, and increased irritability. Hypervigilance refers to an enhanced state of awareness and alertness, often seen in individuals with PTSD as they are constantly on guard for potential threats. Insomnia is a common sleep disturbance associated with PTSD, where individuals may have trouble falling or staying asleep. Flashbacks involve re-experiencing the traumatic event as if it is occurring in the present moment. Suicidal ideation, while a serious concern in mental health, is not a hallmark symptom specifically associated with PTSD. Therefore, the correct finding that the nurse should expect when assessing a client diagnosed with PTSD is hypervigilance.

5. A client has been diagnosed with borderline personality disorder. Which behavior is characteristic of this disorder?

• A. Excessive need for attention
• B. Instability in relationships
• C. Fear of abandonment
• D. Lack of interest in activities

Correct answer: B

Rationale: The correct answer is B: Instability in relationships. Individuals with borderline personality disorder often exhibit instability in their relationships, characterized by intense and unstable interpersonal connections, oscillating between idealization and devaluation. This pattern can lead to frequent conflicts, dramatic emotional shifts, and difficulties maintaining stable relationships. Choices A, C, and D are incorrect. While individuals with borderline personality disorder may also have an excessive need for attention, fear of abandonment, or lack of interest in activities, the hallmark feature defining this disorder is the instability in relationships.

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