PRACTICE SOLUTION STUDY GUIDE
◉ A nurse is reviewing the medication administration record for a
client who is experiencing adverse effects of chlorpromazine. The
nurse should administer benztropine to relieve which of the
following adverse effects?
a. Blurred vision
b. Orthostatic hypotension
c. Dry mouth
d. Acute dystonia. Answer: d. Acute dystonia
The nurse should administer benztropine, an anticholinergic agent,
to relieve acute dystonia, which is an extrapyramidal adverse effect
of chlorpromazine.
◉ A nurse is caring for a client in a mental health facility. The nurse
overhears another staff member make derogatory comments to the
client. Which of the following actions should the nurse take?
a. Confront the staff member.
b. Encourage the client to report the incident.
,c. Document the incident in the client's health record.
d. Report the occurrence to the charge nurse.. Answer: d. Report the
occurrence to the charge nurse.
It is the responsibility of the charge nurse and the nurse manager to
confront the staff member about the derogatory comments made to
the client.
◉ A client who has a diagnosis of depression is attending group
therapy. During the group meeting, the nurse asks each member to
identify one goal for the day. When it is the client's turn, they do not
respond. Which of the following actions should the nurse take before
repeating the request to the client?
a. Allow the client time to formulate an answer.
b. Prompt the client to give a response.
c. Move on to the next client.
d. Offer the client a suggestion for a goal.. Answer: a. Allow the client
time to formulate an answer.
Slowed response time is common in clients who have depression.
The nurse should allow the client time to comprehend and formulate
an answer to the question.
,◉ A nurse is caring for a client who has antisocial personality
disorder and is receiving behavioral therapy through operant
conditioning. Which of the following client behaviors indicates
effectiveness of the therapy?
a. Controls anger outbursts to avoid being placed in seclusion.
b. No longer exhibits a fear of social or public situations.
c. Refrains from manipulating others to earn dining room privileges.
d. Imitates the therapist's use of a relaxation technique.. Answer: c.
Refrains from manipulating others to earn dining room privileges
The goal of operant conditioning is to provide positive
reinforcement in return for a desired behavior. Refraining from
manipulative behavior is a desired response.
◉ A nurse observes a client on a mental health unit pushing on the
locked unit door. Which of the following statements should the nurse
make?
a. "It appears as though you would like to open the door."
b. "You will feel more comfortable after you've been here for a
while."
c. "It is okay to not want to be here."
, d. "You really shouldn't be pushing on the door.". Answer: a. "It
appears as though you would like to open the door."
This statement is an example of the therapeutic technique of making
observations. This technique encourages the client to notice the
behavior so that they can describe thoughts and feelings related to
that behavior.
◉ A nurse is providing teaching to the partner of a client who is in a
rehabilitation program for alcohol use disorder. The nurse should
identify that which of the following statements by the client's
partner indicates an understanding of the teaching?
a. "I will avoid social events until my partner has completed
treatment."
b. "It is important for me to focus my attention on my partner's
addiction."
c. "I will not take charge of my partner's work responsibilities."
d. "I want my partner to promise to change addictive behaviors.".
Answer: c. "I will not take charge of my partner's work
responsibilities."
The nurse should identify that it is important for the individual who
has the substance use disorder to take charge of personal
responsibilities.