A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse not monitor for? Select all that apply.

Correct Answer: A

Rationale: The nurse should not monitor for tardive dyskinesia as it is a potential long-term side effect of antipsychotic medications. However, the nurse should monitor for neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia as these are common side effects associated with antipsychotic medications. Tardive dyskinesia is characterized by involuntary movements of the face, tongue, and extremities and may develop after prolonged use of antipsychotic drugs.

Correct Answer: C

Rationale: In obsessive-compulsive disorder (OCD), common findings include recurrent, intrusive thoughts (obsessions), compulsive behaviors, and avoidance of situations that trigger obsessions. Delusions of grandeur, which involve having an exaggerated sense of power, importance, or identity, are not typically associated with OCD. It is important to differentiate between the specific characteristics of OCD and other mental health conditions to provide accurate care and interventions for clients.

Correct Answer: B

Rationale: The nurse should exclude the instruction to 'Avoid all social interactions' when providing discharge teaching to a client with schizophrenia. It's important for individuals with schizophrenia to continue taking medications as prescribed, report any medication side effects to the healthcare provider, and develop a daily routine to promote stability. Social interactions, albeit with appropriate boundaries, can be beneficial for the client's well-being and integration into the community.

Correct Answer: D

Rationale: Post-traumatic stress disorder (PTSD) is a psychiatric condition that develops after exposure to a traumatic event, characterized by specific symptom clusters including re-experiencing the trauma, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. These symptoms must persist for at least one month and cause significant distress or impairment. When assessing a client with suspected PTSD, the nurse should expect findings aligned with these diagnostic criteria from the DSM-5, but not symptoms from unrelated disorders. Let's examine each option step by step to understand why certain findings are expected in PTSD and why manic episodes are not. First, consider option A: Flashbacks. Flashbacks are a hallmark symptom of PTSD, falling under the re-experiencing cluster. They involve vivid, intrusive recollections where the individual feels as if the traumatic event is recurring in the present moment, often triggered by sensory cues. For example, a combat veteran might suddenly relive a battlefield explosion, experiencing intense fear and disorientation. This is not mere reminiscing but a dissociative-like state that disrupts daily functioning. Nurses should anticipate this in PTSD assessments, as it differentiates PTSD from simple grief or adjustment disorders. Thus, flashbacks are an expected finding. Next, option B: Avoidance of reminders of the trauma. This is a core feature of PTSD, categorized under the avoidance cluster. Individuals actively steer clear of people, places, conversations, or activities that remind them of the trauma to prevent emotional distress. For instance, a survivor of a car accident might refuse to drive or avoid highways, leading to social isolation or occupational interference. This avoidance is persistent and maladaptive, distinguishing it from normal coping after trauma. In nursing assessments, recognizing this helps identify the need for exposure-based therapies like cognitive processing therapy. Therefore, this is a finding the nurse should expect. Now, option C: Increased arousal and hypervigilance. This belongs to the arousal and reactivity cluster in PTSD, manifesting as exaggerated startle responses, irritability, difficulty concentrating, sleep disturbances, and constant scanning for threats (hypervigilance). A client might jump at loud noises or remain perpetually on guard, as if anticipating danger. This physiological hyperarousal stems from dysregulated autonomic nervous system activity post-trauma, often linked to elevated cortisol and adrenaline levels. It's a key diagnostic criterion and can lead to comorbidities like substance abuse if unaddressed. During assessment, nurses observe these signs through behavioral cues or self-reports, making them expected in suspected PTSD. Finally, option D: Manic episodes. Manic episodes are not associated with PTSD; they are defining features of bipolar I disorder. Mania involves a distinct period of abnormally elevated, expansive, or irritable mood lasting at least one week, accompanied by increased energy, grandiosity, decreased need for sleep, racing thoughts, distractibility, and risky behaviors like excessive spending or hypersexuality. These episodes can severely impair judgment and require interventions like mood stabilizers. While trauma can trigger bipolar episodes in predisposed individuals (comorbidity exists), manic symptoms are not inherent to PTSD's diagnostic profile. In PTSD, mood alterations are typically depressive or numbed, not euphoric or manic. Expecting manic episodes in a PTSD assessment would indicate a misdiagnosis or co-occurring condition, so the nurse shouldn't anticipate this as a primary finding. Instead, screening for bipolar disorder separately is advisable if mania is observed. In summary, options A, B, and C directly align with PTSD's symptom clusters, aiding in accurate diagnosis and care planning, such as trauma-focused psychotherapy or medications like SSRIs. Option D, however, points to a different psychopathology, underscoring the importance of differential diagnosis in mental health nursing to avoid conflating disorders and ensure targeted treatment.

Correct Answer: D

Rationale: During a manic episode in bipolar disorder, interventions should focus on providing a structured environment, encouraging rest periods, and setting limits on inappropriate behaviors. Allowing the client to engage in stimulating activities may exacerbate the symptoms of mania, such as increased energy, impulsivity, and risk-taking behaviors. Therefore, it is important to avoid encouraging such activities to prevent worsening of manic symptoms.