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A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Hypotension.
- C. Dry mouth.
- D. Tremors.
Correct Answer: A,D
Rationale: Risperidone can cause weight gain and extrapyramidal symptoms like tremors, which the nurse should monitor.
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The nurse is planning a program about women's health and cancer prevention for a community health fair. The nurse should include information about? Select all that apply.
- A. Regular self-exams of the breast and vulva are important self-care activities.
- B. Cancer can be prevented by removing precancerous lesions of the vulva, cervix, or endometrium.
- C. Girls, age 11 to 12, should receive immunization for human papilloma virus (HPV) to prevent cervical cancer.
- D. Smoking cessation reduces the risk of cervical cancer.
- E. There is limited evidence that cancer in women is inherited.
Correct Answer: A,B,C
Rationale: Self-exams, removal of precancerous lesions, and HPV vaccination are key prevention strategies. Smoking cessation reduces lung cancer risk, not cervical. Some cancers have genetic links.
Which of the following actions is most appropriate when dealing with a client who is beginning to express anger verbally, is pacing, and is irritable?
- A. Conveying empathy and encouraging ventilation.
- B. Using calm, firm directions to get the client to a quiet room.
- C. Putting the client in restraints.
- D. Discussing alternative strategies for when the client is angry in the future.
Correct Answer: B
Rationale: Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.
- A. Excessive alcohol use.
- B. Gallstones.
- C. Abdominal trauma.
- D. Hypertension.
- E. Hyperlipidemia with excessive triglycerides.
- F. Hypothyroidism.
Correct Answer: A,B,C,E
Rationale: Excessive alcohol use, gallstones, abdominal trauma, and hyperlipidemia with high triglycerides are established risk factors for pancreatitis, as they can disrupt塌 or obstruct pancreatic ducts or cause inflammation.
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply.
- A. Call his family to come in to visit with him.
- B. Notify his health care provider of the change.
- C. Place respiratory resuscitation equipment in the client's room.
- D. Check for advancing levels of paresthesia.
- E. Perform ankle pumps to increase circulation and relieve numbness.
Correct Answer: B,C,D
Rationale: Rapidly progressing numbness suggests a neurological condition like Guillain-Barré syndrome, requiring immediate provider notification (B), monitoring for respiratory involvement with resuscitation equipment (C), and ongoing assessment of paresthesia (D). Family visits and ankle pumps are not priorities.
The nurse is caring for a preterm neonate in the NICU. Which intervention is essential to prevent retinopathy of prematurity?
- A. Monitor oxygen saturation
- B. Administer vitamin D
- C. Provide high-calorie formula
- D. Keep the incubator at 37°C
Correct Answer: A
Rationale: Excessive oxygen can contribute to retinopathy of prematurity in preterm neonates. Monitoring oxygen saturation ensures levels remain within a safe range.