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A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?
- A. Hypoactive bowel sounds in all four quadrants.
- B. Client report of dry mouth.
- C. Constant opening and closing of mouth.
- D. Client report of photosensitivity.
Correct Answer: C
Rationale: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.
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A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?
- A. Gradual onset
- B. Impaired judgment
- C. Difficulty swallowing
- D. Slowed, flat speech
Correct Answer: B
Rationale: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.
A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?
- A. A client who is hearing command hallucinations.
- B. A client who is verbalizing ideas of reference.
- C. A client who is using neologisms.
- D. A client who is demonstrating clang associations.
Correct Answer: A
Rationale: A client who is hearing command hallucinations should be prioritized first because command hallucinations can be particularly dangerous. These hallucinations can involve voices instructing the client to harm themselves or others. Immediate assessment and intervention are crucial to ensure the client's safety and to prevent potential harm.
A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?
- A. You will be given an opioid analgesic before the procedure.
- B. Expect to be confused several hours after the procedure.
- C. You cannot eat or drink for 24 hours before the procedure.
- D. A consent form is not required to have this procedure.
Correct Answer: B
Rationale: Confusion and temporary memory loss are common side effects immediately following ECT. Clients should be informed to expect these cognitive effects, which can last for a few hours to days. Educating the client about these side effects helps prepare them for what to expect post-procedure and ensures they have appropriate support during their recovery period.
A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?
- A. Unable to make simple decisions
- B. Enjoys spending time alone
- C. Exhibits extreme perfectionism
- D. Displays confrontational behavior
Correct Answer: A
Rationale: Individuals with dependent personality disorder often struggle with making simple decisions without excessive advice and reassurance from others. They have a strong need for others to take responsibility for major areas of their lives and can feel helpless when alone. This indecisiveness is a hallmark of the disorder and stems from their lack of self-confidence and reliance on others for guidance and support.
A nurse is reinforcing teaching about home care with the family of a client who has Alzheimer's disease and wanders at night. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom area dark at night.
- B. Have the client exercise 30 minutes before bedtime.
- C. Place the client's mattress on the bedroom floor.
- D. Encourage the client to nap often during the day.
Correct Answer: C
Rationale: Placing the client's mattress on the bedroom floor is a practical safety measure for clients with Alzheimer's disease who wander at night. This approach minimizes the risk of injury from falls, as the client will be closer to the ground. By reducing the height of the bed, families can create a safer sleeping environment and help prevent potential injuries due to wandering and confusion.