Nokea
A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions?
- A. Administer PRN benztropine mesylate (Cogentin) immediately.
- B. Hold the chlorpromazine and notify the medical staff stat.
- C. Place the client in isolation on bedrest in semi-Fowler's position.
- D. Administer acetaminophen 500 mg and place the client on a cooling mattress.
Correct Answer: B
Rationale: Symptoms indicate neuroleptic malignant syndrome, a life-threatening reaction to chlorpromazine. Holding the drug and notifying staff is critical. Options A, C, and D address symptoms but not the cause.
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The nurse is caring for all of the following clients. Who is probably at greatest risk for skin breakdown and will need special nursing care measures?
- A. A 75-year-old who is admitted with a broken hip
- B. An 80-year-old who is admitted with angina
- C. An 85-year-old who is admitted for diagnostic tests
- D. A 78-year-old who is admitted with asthma
Correct Answer: A
Rationale: A broken hip limits mobility, increasing pressure ulcer risk due to prolonged immobility, requiring special skin care measures.
Which of the following indicates that a client is beginning to develop a trusting relationship with the nurse?
- A. The client describes delusions to the nurse.
- B. The client can describe his/her feelings to the nurse.
- C. The nurse feels more comfortable with the client.
- D. The client reports feeling less anxious.
Correct Answer: B
Rationale: Sharing feelings indicates trust, a key to therapeutic relationships. Options A, C, and D are less direct indicators.
The nurse is teaching a young woman how to perform breast self-examination. Which comment, if made by the client, indicates that the teaching has been effective?
- A. I should examine my breasts every year.'
- B. I need to see the doctor every six months for a breast exam.'
- C. I don't need to worry about breast cancer for a few years.'
- D. I should examine all parts of my breasts while both lying down and standing up.'
Correct Answer: D
Rationale: Effective breast self-examination involves checking all breast areas in both lying and standing positions monthly. Yearly exams, frequent doctor visits, or delaying concern are incorrect.
The nurse is bathing a client who has contact isolation ordered. The nurse wears gloves. What else is needed?
- A. Face mask
- B. Sterile gloves
- C. Isolation cap
- D. Isolation gown
Correct Answer: D
Rationale: An isolation gown prevents contact transmission, required alongside gloves for bathing a client in contact isolation.
The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to
- A. Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class
- B. Assist the parents to plan quiet play activities at home
- C. Stress to the parents the need to avoid overexertion
- D. Instruct the parents to avoid contact with persons with infection
Correct Answer: A
Rationale: Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class. While all suggestions are appropriate, the education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency care of their child.