Nokea
A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?
- A. Patient Health questionnaire 9
- B. Mental Status Examination
- C. Brief Psychiatric Rating Scale
- D. Abnormal Involuntary Movement Scale
Correct Answer: D
Rationale: The AIMS is designed to detect tardive dyskinesia, a side effect of antipsychotics. Other tools assess depression, cognition, or general psychiatric symptoms.
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A nurse is caring for a client who is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild bruising.
- B. The client's aPTT is 90 seconds.
- C. The client's blood pressure is 122/80 mm Hg.
- D. The client's urine output is 40 mL/hr.
Correct Answer: B
Rationale: An aPTT of 90 seconds (above therapeutic range of 60-80) suggests excessive anticoagulation, requiring reporting. Bruising, normal BP, and urine output are less urgent.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take?
- A. Encourage the client to eat raw fruits and vegetables.
- B. Monitor the client's white blood cell count.
- C. Administer an antipyretic every 4 hr.
- D. Instruct the client to avoid handwashing.
Correct Answer: B
Rationale: Monitoring WBC count detects neutropenia, critical for infection prevention. Raw produce risks infection, antipyretics aren't routine, and handwashing is essential.
A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a meal to avoid stomach upset.
- B. I might not notice the effects of this medication for several weeks.
- C. I will need to decrease my intake of green, leafy vegetables.
- D. I can take an antacid with this medication if I get heartburn.
Correct Answer: B
Rationale: Levothyroxine's effects take weeks to manifest, reflecting proper understanding. It's taken on an empty stomach, diet doesn't need altering, and antacids can interfere.
A nurse on a medical surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?
- A. A client who is scheduled for surgery in 2 hr
- B. A client whose blood pressure is 160/90 mm Hg and reports a headache
- C. A client who is postoperative and reports intermittent nausea
- D. A client who is postoperative and has a Jackson Pratt drain
Correct Answer: B
Rationale: Elevated blood pressure with a headache suggests a hypertensive crisis, requiring immediate assessment to prevent complications like stroke. Other conditions are less urgent.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation?
- A. Place a wedge pillow between the client's legs.
- B. Encourage the client to sit in a recliner.
- C. Allow the client to cross their legs when seated.
- D. Instruct the client to bend at the waist when picking up objects.
Correct Answer: A
Rationale: A wedge pillow maintains abduction, preventing hip dislocation. Recliners, leg crossing, or bending at the waist increase dislocation risk.