Medications
Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect?
Correct Answer: A. Seizures
Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Benzodiazepine reversal has correlations with seizures. Seizures may happen more frequently in patients who have been on benzodiazepines for long-term sedation or in patients who are showing signs of severe tricyclic antidepressant overdose. The required dosage of Flumazenil should be measured and prepared by the practitioners to manage seizures. Flumazenil use requires caution in patients relying on a benzodiazepine for seizure control.
Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
Correct Answer: C. Identify anxiety-causing situations
Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Bulimia nervosa is a condition that occurs most commonly in adolescent females, characterized by indulgence in binge-eating, and inappropriate compensatory behaviors to prevent weight gain.
Nurse Dorothy is evaluating care of a client with schizophrenia; the nurse should keep which point in mind?
Correct Answer: A. Frequent reassessment is needed and is based on the client’s response to treatment.
Because the client responds to treatment in different ways, the nurse must constantly evaluate the client and his potential. A premorbid adjustment must also be considered. Assess if incoherence in speech is chronic or if it is more sudden, as in an exacerbation of symptoms. Establishing a baseline facilitates the establishment of realistic goals, the foundation for planning effective care.
Which of the following conditions is likely to coexist in clients with a diagnosis of borderline personality disorder?
Correct Answer: A. Depression
Chronic feelings of emptiness and sadness predispose a client to depression. About 40% of the clients with borderline struggle with depression. Individuals with BPD have difficulties related to the stability of their sense of self. They report many ups and downs in how they feel about themselves. One moment they may feel good about themselves, but the next they may feel they are bad or even evil.
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?
Correct Answer: C. Schedule for A STAT computer tomography (CT) scan of the head.
A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions.
Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level?
Correct Answer: D. Acetylcysteine (Mucomyst)
The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Acetaminophen (N-acetyl-para-aminophenol, paracetamol, APAP) toxicity is common primarily because the medication is so readily available, and there is a perception that it is very safe. More than 60 million Americans consume acetaminophen on a weekly basis. All patients with high levels of acetaminophen need admission and treatment with N-acetyl-cysteine (NAC). This agent is fully protective against liver toxicity if given within 8 hours after ingestion.
During postprandial monitoring, a female client with bulimia nervosa tells the nurse, “You can sit with me, but you’re just wasting your time. After you had sat with me yesterday, I was still able to purge. Today, my goal is to do it twice.” What is the nurse’s best response?
Correct Answer: D. “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.”
This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Since recovery involves patients having to face their deepest, most painful, and traumatic thoughts and emotions, supporting them as they go through treatment can be emotionally challenging for nurses. This emotional challenge can be exacerbated when the patient has also been diagnosed with Obsessive-Compulsive Disorder (OCD), depression, or substance abuse, as these may require more intensive one-to-one support.
Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?
Correct Answer: B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
The nurse must realize that these perceptions are very real to the client. Acknowledging the client’s feelings provides support; explaining how the nurse sees the situation in a different way provides reality orientation. Recognize the client’s delusions as the client’s perception of the environment. Recognizing the client’s perception can help you understand the feelings he or she is experiencing.
Which of the following nursing interventions has priority for a client with borderline personality disorder?
Correct Answer: A. Maintain consistent and realistic limits.
Clients with borderline who are needy, dependent, and manipulative will benefit greatly from maintaining consistent and realistic limits. Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse’s immediate attention.
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
Correct Answer: C. Activity of the brain.
An EEG measures the electrical activity of the brain. An electroencephalogram (EEG) is an essential tool that studies the brain’s electrical activity. It is primarily used to assess seizures and conditions that may mimic seizures. It is also useful to classify seizure types, assess comatose patients in the intensive care unit, and evaluate encephalopathies, among other indications.
Nurse Maureen knows that the non-antipsychotic medication used to treat some clients with schizoaffective disorder is:
Correct Answer: C. lithium carbonate (Lithane)
Lithium carbonate, an antimanic drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including manic-like activity. Lithium helps control the affective component of this disorder. Lithium was the first mood stabilizer and is still the first-line treatment option, but is underutilized because it is an older drug. Lithium is a commonly prescribed drug for a manic episode in bipolar disorder as well as maintenance therapy of bipolar disorder in a patient with a history of a manic episode. The primary target symptoms of lithium are mania and unstable mood.
Nurse Krina recognizes that the suicidal risk for depressed client is greatest:
Correct Answer: A. As their depression begins to improve
At this point, the client may have enough energy to plan and execute an attempt. All patients with depression should be evaluated for suicidal risk. Any suicide risk must be given prompt attention which could include hospitalization or close and frequent monitoring. Major depression has very high morbidity and mortality contributing to high rates of suicide. Even though effective drug treatment is available, nearly 50% may not initially respond. Complete remission is not common but at least 40% achieve partial remission in 12 months. Depression accounts for nearly 40,000 cases of suicide each year in the US. The highest rate of suicides is in older men.
A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client’s:
Correct Answer: A. Thinking, perceiving, and decision-making skills
Nursing assessment of a psychotic client should include careful inquiry about and observation of the client’s thinking, perceiving, symbolizing, and decision-making skills and abilities. Assessment of such a client typically reveals alterations in thought content and process, perception, affect, and psychomotor behavior; changes in personality, coping, and sense of self; lack of self-motivation; presence of psychosocial stressors; and degeneration of adaptive functioning.
Situation: A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and hyperactive. Initially, the nurse should plan this for a manic client:
Correct Answer: A. Set realistic limits to the client’s behavior
The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. Maintain a consistent approach, employ consistent expectations, and provide a structured environment. Clear and consistent limits and expectations minimize the potential for the client’s manipulation of staff.
The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?
Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS) characterized by inflammation, demyelination, gliosis, and neuronal loss. Neurological symptoms vary and can include vision impairment, numbness and tingling, focal weakness, bladder and bowel incontinence, and cognitive dysfunction. Symptoms vary depending on lesion location.
Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the tricyclic antidepressants. After teaching the client about the medication, Nurse Marian evaluates that learning has occurred when the client states, “I will avoid:
Correct Answer: B. Chocolate milk, aged cheese, and yogurt’”
These high-tyramine foods, when ingested in the presence of an MAO inhibitor, cause a severe hypertensive response. MAOIs prevent the breakdown of tyramine found in the body as well as certain foods, drinks, and other medications. Patients that take MAOIs and consume tyramine-containing foods or drinks will exhibit high serum tyramine level. A high level of tyramine can cause a sudden increase in blood pressure, called the tyramine pressor response.Even though it is rare, a high tyramine level can trigger a cerebral hemorrhage, which can even result in death.
Erlinda, age 85, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find:
Correct Answer: D. Transitory short and long-term memory loss and confusion
ECT commonly causes transitory short and long-term memory loss and confusion, especially in geriatric clients. It rarely results in permanent short and long-term memory loss. The most persistent adverse effect is retrograde amnesia. Shortly after ECT, most patients have gaps in their memory for events that occurred close in time to the course of ECT, but the amnesia may extend back several months or years. Retrograde amnesia usually improves during the first few months after ECT.
A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction?
Correct Answer: A. Dystonia
Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs. Dystonia is a dynamic disorder that changes in severity based on the activity and posture. Dystonia may assume a pattern of overextension or over-flexion of the hand, inversion of the foot, lateral flexion or retroflection of the head, torsion of the spine with arching and twisting of the back, forceful closure of the eyes, or a fixed grimace. It may come to an end when the body is in action and during sleep.
One morning the nurse sees the client in a depressed mood. The nurse asks her “What are you thinking about?” This communication technique is:
Correct Answer: D. Giving broad opening
Broad opening technique allows the client to take the initiative in introducing the topic. Therapeutic communication is often most effective when patients direct the flow of conversation and decide what to talk about. To that end, giving patients a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” can be a good way to allow patients an opportunity to discuss what’s on their mind.
The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?
Correct Answer: B. Restraining the client’s limbs.
The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent?
Correct
Correct Answer: C. Emotional lability, euphoria, and impaired memory
Signs of antianxiety agent overdose include emotional lability, euphoria, and impaired memory. The classic presentation in patients with isolated benzodiazepine overdose will include central nervous system (CNS) depression with normal or near-normal vital signs. Many patients will still be arousable and even provide a reliable history. Classic symptoms include slurred speech, ataxia, and altered mental status.
When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly:
Correct Answer: D. After going to bed
Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Be alert for signs of increasing fear, anxiety or agitation. Might herald hallucinatory activity, which can be very frightening to client, and client might act upon command hallucinations (harm self or others). Explore how the hallucinations are experienced by the client. Exploring the hallucinations and sharing the experience can help give the person a sense of power that he or she might be able to manage the hallucinatory voices.
Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?
Correct Answer: B. Report a sore throat or fever to the physician immediately.
A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. The risk of developing agranulocytosis is around 1% in patients who take clozapine, which may be independent of dosing. Most cases occur early in the treatment, within six weeks to six months, and require extensive monitoring of blood absolute neutrophil counts. The definition of neutropenia is an ANC level below 1500/mm, and agranulocytosis is an ANC level below 500/mm.
The nurse ensures a therapeutic environment for the client. Which of the following best describes a therapeutic milieu?
Correct Answer: C. A living, learning, or working environment.
A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms, limit setting, balance and unit modification.
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by:
Correct Answer: D. Taking medications on time to maintain therapeutic blood levels
Taking medications correctly to maintain blood levels that are not too low or too high is important. The complication of myasthenia gravis includes myasthenic crisis, usually secondary to infections, stress, or acute illnesses. Patients are advised to take their medications as directed and to avoid taking new medicines without checking with the medical provider.