A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

"You may experience dizziness upon standing while taking this medication.”

"This medication will decrease your symptoms of OCD.”

"You can stop taking the medication if the side effects are bothersome.”

"This medication may cause excessive salivation.”

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "You may experience dizziness upon standing while taking this medication."

Choice A rationale:

This choice is the correct answer because haloperidol, an antipsychotic medication, can cause orthostatic hypotension, which leads to dizziness upon standing. Antipsychotic medications often affect blood pressure regulation and can result in a sudden drop in blood pressure when transitioning from sitting or lying down to standing. This explanation provides essential information to the client to help them understand potential side effects and take necessary precautions.

Choice B rationale:

This choice is incorrect. Haloperidol is not indicated for treating symptoms of obsessive-compulsive disorder (OCD). It is primarily used to manage symptoms of schizophrenia and other psychotic disorders. Providing false information about its indications is not appropriate and may lead to confusion.

Choice C rationale:

This choice is incorrect. Clients should never stop taking antipsychotic medications abruptly without consulting their healthcare provider. Discontinuing such medications can lead to withdrawal effects and a worsening of symptoms. Encouraging the client to stop the medication if side effects are bothersome is not appropriate and could potentially jeopardize their well-being.

Choice D rationale:

This choice is partially correct but not the best answer. While haloperidol can cause excessive salivation (sialorrhea) as a side effect, the primary concern in this situation should be related to orthostatic hypotension and dizziness upon standing. Mentioning excessive salivation would be helpful, but it's secondary to the risk of falls associated with orthostatic hypotension.

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Correct Answer is A

Explanation

The correct answer is choice A: Set limits for the relationship.

Choice A rationale:

Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance.Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.

Choice B rationale:

Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.

Choice C rationale:

Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.

Choice D rationale:

Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.

A. "His cousin committed suicide a few weeks ago.” B. "He spends much of his time with his two school friends.” C. "He has slept 9 hours each night for the past 2 years.” D. "He is very religious and attends services twice a week.”

Correct Answer is A

Explanation

Choice A rationale:

"His cousin committed suicide a few weeks ago." This statement is a significant red flag indicating a higher risk of suicide. When an adolescent is exposed to suicide, especially within their family or close social circle, they become more vulnerable due to the potential for social contagion. This scenario increases the urgency for intervention and support to prevent a similar outcome.

Choice B rationale:

"He spends much of his time with his two school friends." While changes in social behavior might raise concerns, this statement alone does not directly indicate a risk of suicide. Adolescents can experience shifts in their social preferences for various reasons, and it's not a definitive sign of suicidal ideation or intent.

Choice C rationale:

"He has slept 9 hours each night for the past 2 years." Sleeping patterns alone do not strongly correlate with suicide risk. However, drastic changes in sleep patterns, such as insomnia or hypersomnia, might be indicative of underlying mental health issues. In this case, the consistent sleep pattern mentioned does not directly signal a risk of suicide.

Choice D rationale:

"He is very religious and attends services twice a week." Religious involvement can have protective effects on mental health, and attending religious services can provide a support network. While religion might offer some resilience against suicide, it is not a definitive indicator. Other factors need to be considered in conjunction with religious activities. For , the statement indicating an adolescent's higher risk of suicide is "His cousin committed suicide a few weeks ago" (Choice A). This experience increases the risk due to the potential for social contagion. The other options, including spending time with school friends, sleep patterns, and religious involvement, do not directly suggest an imminent risk of suicide.

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A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

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