A nurse is caring for a client who receives a new prescription for clozapine (Clozaril). Which of the following is a contraindication to this medication? - ANS-Bone marrow depression A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse use to handle the client's ritualistic behavior? - ANS-Plan the client's schedule to allow time for rituals A nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? - ANS-Command hallucination A nurse is an emergency department is caring for a client who has been taking haloperidol (Haldol) for the past 3 months. The client has a temperature of 38.9 C (102 F), a blood pressure of 150/110 mm Hg, and tachycardia. The nurse should know that these manifestations indicate a diagnosis of: - ANS-neuroleptic malignant syndrome (NMS). A nurse is caring for a client who has delusional behavior and states, "I can't go to group today. I am expecting a high level official to visit today!" The nurse responds, "I understand, but it is time for group and we expect everyone to attend. Let's walk over together." Why is this nurse's response considered therapeutic? - ANS-I clearly articulates what is expected of the client A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications. Findings include muscle rigidity, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring? - ANS-Neuroleptic malignant syndrome A nurse on the psychiatric unit is caring for a client who has moderate anxiety disorder. Which of the following measures should the nurse include in the immediate plan of care? - ANS-Foresee anxiety-provoking circumstances (helps to avoid escalation of anxiety) A nurse is caring for a client who receives a prescription for a benzodiazepine. Which of the following is a contraindication to this medication? - ANS-Alcohol abuse A nurse is caring for a client who is admitted with acute psychosis and is being treated with haloperidol (Haldol). The nurse should suspect that the client may be experiencing tardive dyskinesia as an adverse reaction when the client exhibits which of the following? (Select all that apply.) - ANS-Tongue thrusting and lip smacking Facial grimacing and eye blinking Repetitive involuntary movements A nurse is caring for a client who reports acute anxiety. Which of the following is the priority nursing action? - ANS-Remain with the client A client is admitted with post-traumatic stress disorder following a fire. Which of the following should the nurse recognize as an adaptive defense mechanism? - ANSThe client begins reading a book when he experiences hand tremors in response to loud noise (temporarily blocking memories and perceptions from conscious thought) A nurse is assessing for the presence of extrapyramidal side effects (EPSs) in a client who is taking chlorpromazine (Throazine). Which of the following findings should the nurse recognized as EPSs? (Select all that apply.) - ANS-Muscle contractions of the neck Fidgeting behavior Impaired gait A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates concrete thinking? - ANS-"I am aware that each problem has only one solution." A nurse is providing teaching for a client who has a new prescription for clozapine (Clozaril). When discussing adverse effects, which of the following should the nurse state is the most common? - ANS-Tachycardia A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements by the nurse is appropriate? - ANS-"You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following interventions are appropriate? (Select all that apply.) - ANS-Establish rapport with the client Identify the cause of the anxiety Validate the client's feelings A nurse is providing teaching for a client who has a new prescription for clozapine (Clozaril). Which of the following client statements indicates a need for further teaching? - ANS-"This medication will help prevent seizures." A nurse is assessing a client who has been receiving treatment for schizophrenia with the typical antipsychotic fluphenazine (Prolixin) for 12 months. The nurse observes that the client has fine, fasciculating tongue movements. The nurse correctly associates this finding with which of the following? - ANS-Early symptoms of tardive dyskinesia (TD).