Nokea
A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I may be more sensitive to the sun while taking this medication.
- B. The medication may cause urinary incontinence.
- C. I may experience a metallic taste while taking this medication.
- D. The medication may cause ringing in my ears.
Correct Answer: A
Rationale: Haloperidol can increase photosensitivity, causing the skin to be more sensitive to sunlight, potentially leading to sunburn. Patients should be advised to use sunscreen and wear protective clothing. This statement shows the client understands a key side effect.
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Nurses' Notes
0800: Client is 3 days postoperative. Currently disoriented to time and place, oriented to self. Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times. Client attempts to get out of bed without assistance. Changes in client's behavior began the prior evening and client has been awake most of the night. Client has refused to eat or drink since the previous day. Intake and output from previous day: 250 mL intake, 2,500 mL output. Call placed to provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per provider's prescription. Client continues to be restless.
Vital Signs
• Heart rate: 115/min
• Respiratory rate: 20/min
• Blood pressure: 90/65 mm Hg
• Temperature: 38.6°C (101.5°F)
A nurse is caring for an older adult client who is postoperative.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 arameters the nurse should monitor to collect data about the client's progress.
- A. Delirium,Depression,Alzheimer's disease,Generalized anxiety disorder
- B. Encourage family members to stay with the client,Assist the client to identify coping skills,Monitor the client's fluid intake and output,Encourage the client to exercise.
- C. Suicidal ideation,Weight loss,Fall risk,Sleep-wake cycle
Correct Answer: A
Rationale: Delirium fits acute postoperative confusion. Family presence reassures, fluid monitoring addresses dehydration, and tracking fall risk and sleep assess safety and recovery.
A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. Currently married.
- B. Access to guns in the home.
- C. Terminal liver cancer.
- D. Alcohol use disorder.
Correct Answer: B,C,D
Rationale: Access to guns in the home, terminal liver cancer, and alcohol use disorder are significant risk factors for suicide. Guns increase lethality, terminal illness causes distress, and alcohol impairs judgment and increases impulsivity, all elevating suicide risk.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake
- B. and I won't let it take all of my blood.' Which of the following responses should the nurse make?
- C. I don’t see a snake, but that must be scary for you.
- D. I’m using a syringe to obtain your blood, not a snake.
- E. Your provider requires this blood specimen.
- F. You must be mistaken.
Correct Answer: A
Rationale: Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety. This empathetic response supports the client’s emotional state.
A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?
- A. Arrange for the sibling to visit the client in the dayroom.
- B. Refer the sibling to the client's provider.
- C. Tell the sibling the client does not want visitors.
- D. Encourage the client to visit with the sibling.
Correct Answer: C
Rationale: Informing the sibling that the client does not want visitors respects the client’s wishes and maintains their autonomy and confidentiality. This action upholds the client’s rights without pressuring them.
A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?
- A. Document the client's behavior in the medical record every 1 hr.
- B. Keep staff interactions with the client to a minimum.
- C. Request the provider renew the prescription in 24 hr.
- D. Provide range-of-motion exercises to all extremities every 2 hr.
Correct Answer: D
Rationale: Providing range-of-motion exercises every 2 hours helps to prevent complications associated with immobility, such as muscle atrophy and pressure ulcers. This is a critical safety measure for clients in restraints.