NCLEX RN EXAM/PREPARATION

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Question 1 WRONG Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck a... nd jaw spasms. What should the nurse do? A Assume that the client is posturing. B Tell the client to lie down and relax. Evaluate the client for adverse reactions to haloperidol. Put the client on the list for the physician to see tomorrow Question 1 Explanation: An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn’t the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms. When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait. Question 2 WRONG The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid: has a more predictable onset of action. B produces fewer anticholinergic effects. produces fewer drug interactions. D has a longer duration of action. Question 2 Explanation: A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable. Question 3 WRONG Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s interpersonal communication with the client and specific nursing interventions must be: A clearly identified with boundaries and specifically defined roles. B warm and nonthreatening. centered on clearly defined limits and expression of empathy. flexible enough for the nurse to adjust the plan of care as the situation warrants. Question 3 Explanation: A flexible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and is in control of himself at various times, the nurse must be able to adjust nursing care as the situation warrants. The nurse’s role should be clear; however, the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia fears closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering interventions on clearly defined limits is impossible because the client’s situation may change without warning. Question 4 WRONG The definition of nihilistic delusions is: [Show More]

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