The nurse is caring for a client with schizoaffective disorder and type 2 diabetes mellitus who receives a prescription for a second generation antipsychotic. The client expresses concern to the nurse about the effect of this antipsychotic on blood glucose levels. Which response should the nurse make?

"This medication may cause watery eyes and diarrhea. These will go away within 2 weeks."

"Side effects are not likely with this type of medication. There should be no need to worry."

"I can provide an education sheet with your discharge papers. What is your primary language?"

"This type of medication is generally well tolerated. Tell me more about your concerns."

Answer and Explanation

The Correct Answer is D

Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.

Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.

Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.

Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.

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Correct Answer is A

Explanation

Choice A rationale: Altruism involves addressing one's own needs through meeting the needs of others, and caring for the husband's aging parents is an example of this coping mechanism.

Choice B rationale: Regression involves reverting to an earlier stage of development, which is not evident in the scenario.

Choice C rationale: Compartmentalization is the defense mechanism of separating conflicting thoughts or feelings, which is not clearly identified in the scenario. Choice D rationale: Egocentrism involves seeing the world from only one's own perspective, which is not the primary issue in the scenario.

A. Monitor the client carefully for binging activities. B. Assess and report the client's electrolyte status to the healthcare provider. C. Assign the client's care to a nurse of approximately the same age. D. Schedule the client for group therapy with other bulimic clients.

Correct Answer is B

Explanation

Choice A rationale: Monitoring for binging activities is important, but addressing the potential physiological complications of bulimia, such as electrolyte imbalances, takes precedence.

Choice B rationale: Assessing and reporting the client's electrolyte status is the highest priority as bulimia nervosa can lead to severe electrolyte imbalances, which may result in life-threatening complications.

Choice C rationale: Assigning care based on age is not a priority in addressing the immediate health risks associated with bulimia nervosa.

Choice D rationale: While group therapy is beneficial, addressing the client's physical health and safety is the highest priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

Correct Answer is A

Explanation

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

Correct Answer is B

Explanation

The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first?

A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?