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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 in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?
- A. Determine whether the client's goals are met.
- B. Collect data about the client's current health status.
- C. Provide the client with information on problem-solving.
- D. Establish a regular meeting time with the client.
Correct Answer: C
Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.
A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Involved in community activities.
- C. Submissive personality.
- D. Absence of impulsive behaviors.
Correct Answer: A
Rationale: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms.
A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?
- A. Serum creatinine.
- B. Thiamine level.
- C. Urinalysis.
- D. Erythrocyte sedimentation rate.
Correct Answer: B
Rationale: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.
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 about naltrexone. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will not experience alcohol withdrawal if I take this medication.
- B. The medication will allow me to gradually decrease my alcohol intake.
- C. If I drink alcohol with this medication, I will experience ringing in my ears.
- D. Taking this medication will reduce my cravings for alcohol.
Correct Answer: D
Rationale: This statement accurately reflects one of the primary effects of naltrexone. The medication helps reduce cravings for alcohol, making it easier for individuals to maintain abstinence and avoid relapse. By understanding this aspect of naltrexone, the client demonstrates a clear understanding of its purpose and use in alcohol dependence treatment.