B Chewing sugarless gum can help the client cope with dry mouth, a potential anticholinergic effect on fluphenazine a nurse is teaching a client who has schizophrenia, strategies to cope with anticholinergic effects of fluphenazine. Which of the following should the nurse suggest to the client to m...
NUR 114 Test 2 Questions and Complete
Solutions
B
Chewing sugarless gum can help the client cope with dry mouth, a potential
anticholinergic effect on fluphenazine ✅a nurse is teaching a client who has
schizophrenia, strategies to cope with anticholinergic effects of fluphenazine. Which of
the following should the nurse suggest to the client to minimize anticholinergic effects?
A. Take the medication in the morning to prevent insomnia
B. Chew sugarless gum to moisten the mouth
C. Use cooling measures to decrease fever
D. Take an antacid to relieve nausea
A, b, d
A client who takes a conventional antipsychotic medication should have the greatest
improvement in positive manifestations, hallucinations, bizarre behavior, and
disorganized speech ✅a nurse is following up with a client who takes chloropromazine
for the treatment of schizophrenia. The nurse should expect to find the greatest
improvement in which of the following manifestations? Select all that apply
A. Disorganized speech
B. Bizarre behavior
C. Impaired social interactions
D. Hallucinations
E. Decreased motivation
A, c, d, e ✅a nurse is completing an admission assessment for a client who has
schizophrenia. Which of the following findings should the nurse document as positive
symptoms? Select all that apply
A. Auditory hallucination
B. Lack of motivation
C. Use of clang association
D. Delusion of persecution
E. Constantly waving arms
F. Flat affect
B
This comment indicates the client is experiencing a loss of identity or depersonalization
✅a nurse is caring for a client who has schizoaffective disorder. Which of the following
statements indicates the client is experiencing depersonalization?
A. I am a superhero and am immortal
B. I am no one and everyone is me
C. I feel monsters pinching me all over
D. I know that you are stealing my thoughts
,B
Ask the client directly about the hallucination to identify client needs and assess for a
potential risk for injury ✅a nurse is speaking with a client who has a schizophrenia
when the client suddenly seems to stop focusing on the nurses questions and begins
looking at the ceiling and talking to themselves. Which of the following actions should
the nurse take?
A. Stop interviewing at this point and resume alter when the client is better able to
concentrate
B. Ask the client are you seeing something on the ceiling?
C. Tell the client you seem to be looking at something on the ceiling i see something
there too
D. Continue to interview without comment on the clients behavior
D
The nurse in the psychiatric nursing assistant spend more time with the patients and
any of the other members of the healthcare team. Thus establishing a good therapeutic
relationship is essential to building trust increasing social skills and encouraging
participation in educational socialization and vocational opportunities. Conventional
psychotherapy is generally not used with patients with schizophrenia ✅the nurse is
caring for patients who have schizophrenia. In addition to medication multidisciplinary
non-drug therapies are available. What is the nurses most important role in helping the
patients to benefit from this comprehensive approach?
A. Help identify patients who would benefit from conventional therapy
B. Refer patients to a psychiatric nurse specialist for education about the disease
C. Suggest that patients talk to vocational specialist for additional training
D. Establish a therapeutic relationship with patients and encourage participation
D
The nurse can acknowledge the patient's fears without agreeing or disagreeing with his
accusations toward Dr. Smith. Directing him to talk to one of the nursing staff provides a
source of emotional support in an action that he can use to decrease his anxiety. Telling
the patient that no one has died and that the other staff were interested in is presenting
reality however he believes that someone has been killed and that Dr. Smith is reliable
so this opens opportunities for argument. Asking him to explain his rationale for his
belief encourages him to elaborate on his delusion ✅a patient diagnosed with paranoid
schizophrenia tells the nurse that dr smith has killed several other patients and now he
is trying to kill me. What is the best response?
A. I have worked here a long time. No one has died. You are safe here
B. What has dr smith done to make you think he would like to kill you
C. All of the staff including dr smith are here to ensure your safety
D. Whenever you are concerned or nervous talk to me or any of the nurses
A
ANP in a can initiate this simple cooling measure with minimal instruction. Neuroleptic
malignant syndrome is a rare but potentially fatal reaction to antipsychotic medication.
, Symptoms can include fever and altered mental status muscle rigidity autonomic
instability. The RN should continuously interpret vital signs although taking vital signs
can be delegated. Unlicensed assistive personnel in the ICU and ED will be familiar with
How to attach ECG leads but PNA's rarely have occasion to use his equipment
therefore the RN should perform this task. The RN should accompany the assistant
patient to the ICU although the PNA could assist ✅a patient on the acute psychiatric
unit develops neuroleptic malignant syndrome. Which task should be delegated to the
psychiatric NA?
A. Wiping the patients body with cool moist towels
B. Monitoring and interpreting VS every 15 minutes
C. Attaching the client to the ECG monitor
D. Transporting the patient to the medical intensive care unit
B
Weekly wbcs are taken because the client is at risk for fatal agranulocytosis. Initially the
clozapine an atypical antipsychotic medication will not be administered if the WBC count
is not available ✅the client admitted to the psych unit diagnosed with schizophrenia is
prescribed clozapine. Which lab data should the nurse evaluate?
A. The client clozapine therapeutic level
B. The clients WBC count
C. The clients RBC count
D. The clients abgs
C
A side effect of all types of antipsychotics is orthostatic hypotension which can be
minimized by moving slowly when assuming erect posture ✅the client admitted to the
psych unit experiencing hallucinations and delusions is prescribed risperidone. Which
intervention should the nurse implement?
A. Provide the client with a low tyramine diet
B. Assess the clients respiration for 1 full minute
C. Instruct the client to change positions slowly
D. Monitor the clients I&O
D
Ziprasidone an atypical antipsychotic is well tolerated but the most common side effect
is difficulty in sleeping. Perhaps because the antihistamine antagonist blockade effect of
the drug. This comment indicates the client understands the teaching. ✅the male client
diagnosed with schizophrenia is prescribed ziprasidone. Which statement to the nurse
indicates the client understands the medication teaching?
A. I need to keep taking this medication even if i become impotent
B. I should not go out in the sun without wearing protective clothing
C. This medication may cause my breast size to increase
D. I may have trouble sleeping when i take this medication
A, b, e
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