Nokea
A client is given a prescription for an antipsychotic medication. The nurse instructs the client and family to report any signs/symptoms of pseudoparkinsonism and tells the family to monitor for what effects indicative of this medication complication?
- A. Tremors and hyperpyrexia
- B. Motor restlessness and aphasia
- C. Stooped posture and a shuffling gait
- D. Muscle weakness and decreased salivation
Correct Answer: C
Rationale: Pseudoparkinsonism is a common extrapyramidal side effect of antipsychotic medications. This condition is characterized by a stooped posture, a shuffling gait, a masklike facial appearance, drooling, tremors, and pill-rolling motions of the fingers. Hyperpyrexia is characteristic of the extrapyramidal side effect of neuroleptic malignant syndrome. Motor restlessness, aphasia, muscle weakness, and decreased salivation are not characteristic of pseudoparkinsonism.
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A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder?
- A. Exposure to heat
- B. Cigarette smoking
- C. Diet low in vitamin C
- D. Excessive water intake
Correct Answer: B
Rationale: Buerger's disease is an occlusive disease of the median small arteries and veins. It occurs predominantly among men who are more than 40 years old who smoke cigarettes. A familial tendency is noted, but cigarette smoking is consistently a risk factor. Symptoms of the disease improve with smoking cessation. Exposure to heat, diet low in vitamin C, and excessive water intake are not risk factors.
The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching?
- A. I wear an eye patch at night.
- B. I am staying on a liquid diet.
- C. I wear dark glasses when I go out.
- D. I have been gently massaging my face.
Correct Answer: B
Rationale: Bell's palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor. It is not necessary for a client diagnosed with Bell's palsy to stay on a liquid diet. The client should be encouraged to chew on the unaffected side. Wearing an eye patch at night, dark glasses for daytime outings, and gently massaging the face identify accurate statements related to the management of Bell's palsy.
The nurse provides home care instructions to a client who has been diagnosed with recurrent trichomoniasis. The nurse determines the need for follow-up teaching if the client indicates she should take which action?
- A. Avoid sexual intercourse.
- B. Perform good perineal hygiene.
- C. Use the metronidazole as prescribed.
- D. Discontinue treatment during menstruation.
Correct Answer: D
Rationale: Treatment for a recurrent vaginal trichomoniasis infection continues through the menstrual period because the vagina is more alkaline during menses, and a flare-up is more likely to occur. While the infection remains active, the client should refrain from sexual intercourse or instruct her partner to wear a condom. To help break the chain of infection, the nurse directs the client to perform perineal hygiene after each voiding and each bowel movement. Metronidazole must be taken as prescribed.
The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
- A. A smoker who works in an acute care hospital
- B. A person who works with lawn care pesticides
- C. A person who does woodworking as a hobby for 8 years
- D. A smoker who has cracked asbestos lining on the basement pipes
Correct Answer: D
Rationale: The client who smokes and has exposure to cracked asbestos lining is at the highest risk for respiratory disease due to the combined effects of smoking and asbestos, both potent lung irritants. Smoking alone or other exposures (pesticides, woodworking) pose risks, but the dual exposure in option D is the most severe.
The labor and delivery nurse notes that the health care provider has rated a newborn's Apgar score as 9. The nurse understands which to be true regarding Apgar scores?
- A. The optimum score is 10.
- B. A baby with poor activity would rate a 1 in that area.
- C. The highest score that each factor may receive is 3.
- D. Scores are obtained 5 minutes after birth and repeated 5 minutes later.
Correct Answer: A
Rationale: The optimal Apgar score is 10. Each factor scores 0-2, and scores are taken at 1 and 5 minutes post-birth.