PRACTICE 2025
A 60 year old client diagnosed with chronic schizophrenia presents in
an emergency department with uncontrollable tongue movements,
stiff neck, and difficulty swallowing. Which medical diagnosis and
treatment should a nurse anticipate when planning care for this
client?
A. Neuroleptic malignant syndrome treated by discontinuing
antipsychotic medications.
B. Agranulocytosis treated by administration of clozapine (Clozaril).
C. Extrapyramidal symptoms treated by administration of benztropine
(Cogentin).
D. Tardive dyskinesia treated by discontinuing antipsychotic
medications. - ANSWER-Answer:
D. Tardive dyskinesia treated by discontinuing antipsychotic
medications.
(happens after pt has chronically taken antipsychotic medications.
When prescribing antipsychotics, you want to start low and gradually
increase dose because of this. Question clues: "Chronic
schizophrenia", "uncontrollable tongue movements, stiff neck,
difficulty swallowing")
.A client began taking lithium for the treatment of BP disorder
approximately 1 month ago. The client asks if it is normal to have
,gained 12 pounds in this time frame. Which is the appropriate nursing
response?
A. "Thats strange. Weight loss is the typical pattern."
B. "What have you been eating? Weight gain is not usually associate
with lithium."
C. "Weight gain is a common but troubling side effect."
D. "Weight gain only occurs during the first month of treatment with
this drug." - ANSWER-Answer:
C. "Weight gain is a common but troubling side effect."
.A client diagnosed with a history of anorexia nervosa comes to an
outpatient clinic after being medically cleared. The client states, "My
parents watch me like a hawk and never let me out of their sight. "
Which nursing diagnosis would take priority at this time?
A. Altered nutrition less than body requirements
B. Altered social interaction
C. Impaired verbal communication
D. Altered family processes - ANSWER-Answer:
D. Altered family processes
.A client diagnosed with antisocial personality disorder comes to a
nurses' station at 11:00 p.m. requesting to phone a lawyer to discuss
filing for divorce. The unit rules state that no phone calls are
permitted after 10:00 p.m. Which nursing response is most
appropriate?
,A. "Go ahead and use the phone. I know this pending divorce is
stressful."
B. "You know better than break the rules. Im surprised at you. "
C. "It is after the 10:00 p.m. phone curfew. You will be able to call
tomorrow."
D. "The decision to divorce should not be considered until you have
had a good nights sleep." - ANSWER-Answer:
C. "It is after the 10:00 p.m. phone curfew. You will be able to call
tomorrow."
.A client diagnosed with bipolar disorder is distraught over insomnia
experienced over the last 3 nights and a 12- pound weight loss over
the past 2 weeks. Which should be this client's priority nursing
diagnosis?
A. Knowledge deficit R/T bipolar disorder AEB concern about
symptoms.
B. Altered nutrition: Less than body requirements r/t hyperactivity
AEB weight loss.
C. Risk for suicide r/t powerlessness AEB insomnia and anorexia.
D. Altered sleep patterns r/t mania AEB insomnia for the past 3
nights. - ANSWER-Answer:
B. Altered nutrition: Less than body requirements r/t hyperactivity
AEB weight loss. (physical needs/health always priority.)
, .A client diagnosed with bipolar disorder: depressive phase
intentionally overdoses on sertraline (Zoloft). Family members report
that the client has experience anorexia, insomnia, and recent job loss.
What should be the priority nursing diagnosis for this client?
A. Risk for suicide r/t hopelessness.
B. Anxiety: severe r/t hyperactivity
C. Imbalanced nutrition: less than body requirements r/t refusal to
eat
D. Dysfunctional grieving r/t loss of employment. - ANSWER-Answer:
A. Risk for suicide r/t hopelessness.
.A client diagnosed with borderline personality disorder brings up a
conflict with the staff in a community meeting and develops a
following of clients who unreasonably demand modification of unit
rules. How can the nursing staff best handle this situation?
A. Allow the clients to apply the democratic process when developing
unit rules.
B. Maintain consistency of care by open communication to avoid staff
manipulation.
C. Allow the client spokesman to verbalize concerns during a unit staff
meeting.
D. Maintain unit order by the application of autocratic leadership. -
ANSWER-Answer:
B. Maintain consistency of care by open communication to avoid staff
manipulation.