Nokea
A client with schizophrenia spends much of his time pacing the floor, rocking back and forth, and moving from one foot to another. The client's behaviors are an example of:
- A. Dystonia
- B. Tardive dyskinesia
- C. Akathisia
- D. Oculogyric crisis
Correct Answer: C
Rationale: Akathisia is characterized by restlessness and constant movement, often a side effect of antipsychotic medications, as described.
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An RN delegates patient assignments to an LPN and nursing assistant. Later, the RN overhears a nursing assistant arguing with a patient regarding a late breakfast tray. The nursing assistant begins to raise his voice as the disagreement continues. The best action from the RN is
- A. call the nursing assistant out of the room and speak with him about the incident.
- B. apologize to the patient and assign another nursing assistant to that room.
- C. report the nursing assistant to the nursing manager for poor patient care.
- D. write an incident report and give a copy to the nursing assistant and nurse manager.
Correct Answer: A
Rationale: Addressing the nursing assistant privately de-escalates the situation, provides coaching, and maintains professionalism without immediate escalation.
Physician's orders for a client with acute pancreatitis include the following: strict NPO and nasogastric tube to low intermittent suction. The nurse recognizes that witholding oral intake will:
- A. Reduce the secretion of pancreatic enzymes
- B. Decrease the client's need for insulin
- C. Prevent the secretion of gastric acid
- D. Eliminate the need for pain medication
Correct Answer: A
Rationale: Withholding oral intake (NPO) reduces stimulation of the pancreas, thereby decreasing the secretion of pancreatic enzymes that can exacerbate pancreatitis.
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about:
- A. Bleeding precautions
- B. Prevention of falls
- C. Oxygen therapy
- D. Conservation of energy
Correct Answer: A
Rationale: With a platelet count of 80,000, the client is at risk for bleeding, so teaching bleeding precautions is critical to prevent complications.
As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
- A. The baby is sleeping.
- B. The umbilical cord is compressed.
- C. There is head compression.
- D. There is uteroplacental insufficiency.
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency, reducing fetal oxygenation during contractions.
The nurse administers ciproflaxin to a client and then realizes that the client is allergic to the medication. What nursing action is the priority for this client?
- A. induce vomiting
- B. obtain the client's vital signs
- C. complete an incident report
- D. notify the health care provider
Correct Answer: D
Rationale: Notifying the health care provider is the priority to initiate immediate management of a potential allergic reaction, followed by monitoring and reporting.