Nokea
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?
- A. Current vital signs
- B. White blood cell count
- C. 24-hour urinary output
- D. Blood sugar level
Correct Answer: A
Rationale: Current vital signs are critical for assessing NMS, a life-threatening side effect of haloperidol, indicated by fever, unstable blood pressure, and tachycardia. White blood cell count, urinary output, and blood sugar are less specific to NMS.
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In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.
Which individual should the nurse consider at highest risk for suicide?
- A. A retired older male whose significant other has passed away
- B. A nurse who works in a pediatric emergency department
- C. An adolescent male whose parents recently divorced
- D. A single working mother with three pre-school aged children
Correct Answer: C
Rationale: Adolescents experiencing significant life changes like parental divorce are at increased suicide risk due to emotional upheaval and limited coping skills. Older males may have coping mechanisms. Stressful jobs or parenting are less specific risk factors without additional context.
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.
Which reason(s) should the nurse expect a female client to use when she is having difficulty leaving a relationship where she is a victim of intimate partner violence? Select all that apply.
- A. Shame and guilt
- B. Children
- C. Religious beliefs about marriage
- D. The perpetrator will not change
- E. Financial dependency
Correct Answer: A,B,C,E
Rationale: A: Shame and guilt can prevent leaving due to fear of judgment. B: Children influence staying for their well-being or custody concerns. C: Religious beliefs about marriage may emphasize staying. E: Financial dependency is a common barrier. D: Belief the perpetrator won't change is not a reason to stay but rather a reason to leave.
The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
- A. You appear to be speaking with someone
- B. Let's talk about the next time this happens
- C. You need to be calm and focus on something else
- D. The voices you are hearing are not real
Correct Answer: A
Rationale: This comment acknowledges the client's behavior without judgment, validating their experience and encouraging further discussion. Focusing on the future, redirecting, or denying the voices may not be therapeutic and could invalidate the client's reality.