Nokea
A client with schizophrenia is receiving haloperidol (Haldol) 5 mg T.I.D. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct Answer: A
Rationale: Oculogyric crisis. This refers to involuntary muscle spasm of the eye, a known side effect of haloperidol.
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The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is
- A. Eat a balanced diet for your age.
- B. Increase your intake of protein and Vitamin A.
- C. Decrease fatty foods from your diet.
- D. Do not use caffeine in any form, including chocolate.
Correct Answer: A
Rationale: Eat a balanced diet for your age. There are no recommended additions and subtractions from the diet for acne management.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.
The nurse is assisting the RN to develop a nursing care plan for a client who has acute glomerulonephritis. Which of the following should the nurse monitor? Select all that apply.
- A. Urine for protein
- B. Urine for specific gravity
- C. Intake and output
- D. Daily weights
- E. Blood pressure
- F. Serum electrolytes
Correct Answer: A,B,C,D,E,F
Rationale: Glomerulonephritis causes proteinuria, altered urine concentration, fluid retention, hypertension, and electrolyte imbalances; monitoring urine, intake/output, weight, BP, and electrolytes tracks disease progression and complications.
Which of these parents' comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
- A. I noticed a little lump a little above the belly button.
- B. The baby seems hungry all the time.
- C. Mild vomiting turned into vomiting that shot across the room.
- D. We notice irritation and spitting up immediately after feedings.
Correct Answer: C
Rationale: Mild vomiting turned into vomiting that shot across the room. Projectile vomiting is a hallmark of pyloric stenosis.
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
- A. Decrease the rate of the intravenous infusion.
- B. Change the type of intravenous fluid being administered.
- C. Change the urinary catheter.
- D. Increase the rate of the intravenous infusion.
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.