A nurse is caring for a client who was recently re-admitted for relapse of psychosis symptoms due to not taking their medications. Which of the follow should be a long-term goal for this client?

To keep the client's environment calm and with minimal daily stimuli

To be reoriented to their current environment as needed

To ensure the client participates in a walk with staff on a daily basis

To develop and acknowledge understanding of a relapse plan prior to discharge

Answer and Explanation

The Correct Answer is D

A. To keep the client's environment calm and with minimal daily stimuli: While a calm environment can help manage acute psychotic symptoms, it is a short-term intervention rather than a long-term goal. Long-term management focuses on adherence to treatment and relapse prevention.
B. To be reoriented to their current environment as needed: Reorientation is beneficial for clients experiencing disorientation due to acute psychosis, but it is a short-term intervention. A long-term goal should focus on maintaining stability and preventing future relapse.
C. To ensure the client participates in a walk with staff on a daily basis: Regular physical activity can improve mental health, but it does not directly address medication adherence or long-term relapse prevention. The goal should focus on strategies to maintain treatment compliance.
D. To develop and acknowledge understanding of a relapse plan prior to discharge: A relapse plan helps the client recognize early warning signs, understand medication importance, and seek support when needed, which is essential for long-term symptom management and prevention of future hospitalizations.

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Correct Answer is D

Explanation

A. "Lately, I feel like I am more alert than usual and can focus better.": Depression is commonly associated with difficulties in concentration, memory impairment, and slowed cognitive function rather than increased alertness or improved focus. Clients with depression often report feeling mentally sluggish or experiencing brain fog.
B. "I can't sit still. I feel like I need to be doing things around the house.": While some individuals with depression experience psychomotor agitation, it is more common for depression to present with fatigue, low energy, and decreased motivation. Restlessness may also be seen in anxiety disorders, but it is not a primary symptom of depression.
C. "When I went to my provider, they told me I have high blood pressure.": Hypertension is a medical condition that may have various causes, but it is not a direct manifestation of depression. However, chronic stress and depression can contribute to cardiovascular issues over time, though depression itself is primarily characterized by emotional and cognitive symptoms.
D. "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.": Insomnia and difficulty falling or staying asleep are hallmark symptoms of depression. Clients often experience ruminative thoughts, early-morning awakenings, or non-restorative sleep, which can contribute to worsened mood, fatigue, and impaired daily functioning.

A. Severe restlessness B. Respiratory depression and a comatose state C. Sore throat and muscle aches D. Increased anxiety and suicidal ideations

Correct Answer is C

Explanation

A. Severe restlessness. Severe restlessness, known as akathisia, is a potential side effect of antipsychotic medications but is not indicative of agranulocytosis. Akathisia is associated with excessive movement and an inability to stay still, often requiring dose adjustment or medication to alleviate symptoms.
B. Respiratory depression and a comatose state. Respiratory depression and coma are not linked to agranulocytosis but may occur with overdose or central nervous system depression. Agranulocytosis affects white blood cell levels, leading to increased infection risk rather than sedation or respiratory suppression.
C. Sore throat and muscle aches. Sore throat and muscle aches are early signs of agranulocytosis, a potentially life-threatening condition characterized by a dangerously low neutrophil count. Clients taking clozapine must undergo regular white blood cell monitoring to detect agranulocytosis early and prevent severe infections.
D. Increased anxiety and suicidal ideations. Increased anxiety and suicidal ideations may be related to psychiatric conditions or medication effects but are not specific to agranulocytosis. Clozapine is primarily used for treatment-resistant schizophrenia and may help reduce suicidal behavior rather than induce it.

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A nurse is caring for a client who was recently re-admitted for relapse of psychosis symptoms due to not taking their medications. Which of the follow should be a long-term goal for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a primary care clinic is collecting data on a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?

Correct Answer is D

Explanation

A nurse is reinforcing education to a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

Correct Answer is C

Explanation

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