Nokea
A client with a history of schizophrenia is admitted with auditory hallucinations. The nurse should prioritize which of the following interventions?
- A. Provide a quiet environment.
- B. Administer haloperidol as prescribed.
- C. Encourage group therapy immediately.
- D. Restrict the client to their room.
Correct Answer: A, B
Rationale: A quiet environment and haloperidol reduce stimulation and manage hallucinations.
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A client with a diagnosis of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Hypotension.
- C. Dry mouth.
- D. Akathisia.
Correct Answer: A,D
Rationale: Aripiprazole can cause weight gain and akathisia (restlessness), which the nurse should monitor.
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
- A. Restricting visitors with colds or respiratory infections
- B. Removing all live plants, flowers, and stuffed animals in the client's room
- C. Placing the client on a low-bacteria diet that excludes raw foods and vegetables
- D. Padding the side rails and removing all hazardous and sharp objects from the room
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.
A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in his discharge teaching? Select all that apply.
- A. Providing humidity at home.
- B. Following a bland diet.
- C. Learning how to suction himself.
- D. Having communication rehabilitation with a speech pathologist.
- E. Attending a smoking cessation program.
Correct Answer: A,C,D,E
Rationale: After a total laryngectomy, the client needs humidity to keep the airway moist, must learn to suction the airway to maintain patency, requires speech rehabilitation to learn alternative communication methods, and should attend smoking cessation to reduce further risk. A bland diet is not typically required unless specified for other conditions.
Which of these clients is at greatest risk for falls?
- A. A 77 year old female client in a client room that has low glare floors.
- B. An 87 year old female client in a client room that has low glare floors.
- C. A 27 year old sedated male client.
- D. A 37 year old male client with impaired renal perfusion.
Correct Answer: B
Rationale: An 87-year-old female is at the greatest risk for falls due to age-related factors like decreased mobility, balance issues, and potential comorbidities, compared to younger or less impaired clients.
The physician decides to change a client's current dose of I.M. meperidine hydrochloride (Demerol) to an oral dosage. The current I.M. dosage is 75 mg every 4 hours as needed. What dosage of oral meperidine should the client receive?
- A. 100 mg every 4 hours.
- B. 150 mg every 4 hours.
- C. 75 mg every 4 hours.
- D. 50 mg every 4 hours.
Correct Answer: B
Rationale: Oral meperidine has lower bioavailability than I.M., requiring a higher dose. A common conversion is 1.5–2 times the I.M. dose, making 150 mg every 4 hours appropriate.