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A nurse is assessing a client who takes haloperidol (Haldol) for the treatment of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)? Select all.
- A. Orthostatic hypotension
- B. Fine motor tremors
- C. Acute dystonias
- D. Decreased level of consciousness
- E. Uncontrollable restlessness
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. Fine motor tremors, acute dystonias, and uncontrollable restlessness are all extrapyramidal symptoms (EPS) commonly associated with haloperidol use. Fine motor tremors refer to involuntary shaking movements, acute dystonias are sudden muscle contractions causing abnormal postures, and uncontrollable restlessness is known as akathisia. These are classic EPS manifestations caused by dopamine blockade in the basal ganglia. Orthostatic hypotension (A) is a side effect related to alpha-adrenergic blockade, not EPS. Decreased level of consciousness (D) is not typically associated with EPS but may indicate overdose or other complications.
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A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
- A. Keep the head of the bed elevated 30 degrees
- B. Massage the client's bony prominences often
- C. Apply cornstarch liberally to the skin after bathing
- D. Have the client sit on a gel cushion when in a chair
- E. Reposition the client at least Q 3 hr while in bed
Correct Answer: A, D
Rationale: The correct interventions (A and D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.
A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. This device will keep me from getting sores on my skin.
- B. This thing will keep the blood pumping through my leg.
- C. With this thing on, my leg muscles won't get weak.
- D. This device is going to keep my joints in good shape.
Correct Answer: B
Rationale: The correct answer is B: "This thing will keep the blood pumping through my leg." This statement shows understanding because sequential compression devices help prevent blood clots by promoting blood circulation in the legs. Option A is incorrect as the device does not prevent skin sores. Option C is incorrect as it doesn't specifically address blood circulation. Option D is incorrect as the device does not impact joint health.
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
- A. Increase in incisional pain
- B. Fever & chills
- C. Reddened wound edges
- D. Increase in serosanguineous drainage
- E. Decrease in thirst
Correct Answer: A, B, C
Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include: A) Increase in incisional pain: Infection can cause localized pain. B) Fever & chills: Systemic signs of infection. C) Reddened wound edges: Classic sign of wound infection. Incorrect choices: D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.
A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all.
- A. Make sure the surgeon obtained the client's consent
- B. Witness the client's signature on the consent form
- C. Explain the risks and benefits of the procedure
- D. Describe the consequences of choosing not to have the surgery
- E. Tell the client about alternatives to having the surgery
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: The nurse should ensure the surgeon obtained the client's consent as the surgeon is responsible for informing the client about the procedure and obtaining consent.
B: Witnessing the client's signature on the consent form ensures that the client signed voluntarily and with full understanding.
Summary:
C: While explaining risks and benefits is important, it is primarily the surgeon's responsibility.
D: Describing consequences of not having surgery is relevant but not directly related to obtaining informed consent.
E: Although discussing alternatives is crucial, it is not a direct part of the informed consent process.