A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Ask the client, “What are the voices saying to you?”

Give the client a PRN dose of benztropine.

Call and report the behavior to the physician.

Tell the client, “Well, I see you’re distracted right now. We’ll talk more later.”

Answer and Explanation

The Correct Answer is A

The correct answer is a.

Choice A Reason:

The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:

The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.

Choice C Reason:

The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.

Choice D Reason:

The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.

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Correct Answer is ["0.63"]

Explanation

To calculate the correct dose:

Identify the prescribed dose: 5 mg
Identify the concentration of the available morphine: 8 mg/mL
Calculate the volume to be administered:
- Volume (mL) = Prescribed dose (mg) ÷ Concentration (mg/mL)
- Volume (mL) = 5 mg ÷ 8 mg/mL
- Volume (mL) = 0.625 mL

The nurse will give 0.63 mL (rounded to the nearest hundredth) for the correct dose.

A. Changes to behavior and personality B. Past history of head trauma C. Impaired judgment D. Muscle stiffness and shuffling gait E. Diagnosis of hypertension

Correct Answer is ["A","C","D"]

Explanation

Choices A, C, and D: Changes to behavior and personality, Impaired judgment, Muscle stiffness and shuffling gait.

Choice A Reason:

Changes to behavior and personality are hallmark symptoms of frontotemporal dementia (FTD). This condition primarily affects the frontal and temporal lobes of the brain, which are responsible for behavior, personality, and language. Patients often exhibit socially inappropriate behaviors, apathy, and a decline in personal hygiene. These changes are among the earliest and most noticeable symptoms of FTD.

Choice B Reason:

While a past history of head trauma can be a risk factor for various types of dementia, it is not specifically associated with frontotemporal dementia. FTD is more commonly linked to genetic factors and specific protein abnormalities in the brain. Therefore, a history of head trauma is not a typical aspect of the medical history for FTD patients.

Choice C Reason:

Impaired judgment is a common symptom of frontotemporal dementia. The degeneration of the frontal lobes affects executive functions, including decision-making, problem-solving, and judgment. Patients may make poor decisions, exhibit risky behaviors, and have difficulty understanding the consequences of their actions.

Choice D Reason:

Muscle stiffness and a shuffling gait can occur in some forms of frontotemporal dementia, particularly in cases where the condition overlaps with motor neuron disease or Parkinsonism. These physical symptoms are less common than behavioral and cognitive symptoms but can still be present in some patients.

Choice E Reason:

A diagnosis of hypertension is not specifically related to frontotemporal dementia. While hypertension is a common condition that can coexist with any form of dementia, it is not a characteristic feature of FTD. The primary symptoms of FTD are related to changes in behavior, personality, and cognitive functions rather than vascular issues.

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A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["0.63"]

Explanation

A client is admitted to an inpatient unit with a diagnosis of frontotemporal dementia. Which of the following aspects of a medical history would the nurse expect to see with this client? (Select All that Apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse recognizes that a function of the Mental Status Exam is to:

After being in the hospital for one month, a client with schizophrenia states that voices are telling them they will die tonight. The client asks the nurse if this is true. The client’s statement and question indicate that they:

Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?

The nurse is attempting to de-escalate a client who is becoming increasingly agitated on the unit. Which of the following interventions would be appropriate for this type of client? (SELECT ALL THAT APPLY)

The nurse calculates that a patient must receive 1.3 mL of an anti-infective agent. The dose is ordered IM. Which of the following choices demonstrates safe, evidence-based practice?

A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)