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A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?
- A. I check my blood pressure once a week.
- B. I chew sugar-free gum several times daily.
- C. I haven't had a drink of alcohol since I started taking these injections.
- D. I spend several hours a day outside gardening when it's sunny.
Correct Answer: D
Rationale: Spending several hours outside in the sun could increase the risk of photosensitivity, a side effect of haloperidol. The nurse should address this to educate the client on protective measures like sunscreen use.
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A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Cold extremities.
- B. Diarrhea.
- C. Tooth erosion.
- D. Lanugo.
Correct Answer: A,C,D
Rationale: Cold extremities, tooth erosion, and lanugo are common in anorexia nervosa. Poor circulation causes cold extremities, vomiting erodes teeth, and lanugo grows to conserve heat due to fat loss, reflecting the disorder’s physical impact.
A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
- A. Diarrhea.
- B. Hypokinesis.
- C. Bradycardia.
- D. Meiosis.
Correct Answer: A
Rationale: Diarrhea is a common symptom of opioid withdrawal due to increased gastrointestinal motility. This reflects the body’s reaction to the absence of opioids.
A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?
- A. Lanugo.
- B. Muscle wasting.
- C. Hypokalemia.
- D. Hypomagnesemia.
Correct Answer: C
Rationale: Hypokalemia, low potassium levels, is a common finding in bulimia nervosa due to repeated vomiting and laxative use. These behaviors lead to significant electrolyte imbalances, posing serious health risks.
A client is becoming increasingly agitated
- A. anxious
- B. and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?
- C. Verbally de-escalate the client.
- D. Take the client to the seclusion room.
- E. Place the client in restraints.
- F. Obtain a prescription for haloperidol.
Correct Answer: A
Rationale: Verbally de-escalating the client is the first step to reduce agitation and prevent escalation. This non-invasive approach prioritizes safety and communication.
A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?
- A. Implement 24-hr one-to-one nursing observation.
- B. Document the client's behavior every 2 hr.
- C. Restrict interactions with other clients.
- D. Administer prescribed medication via the IM route.
Correct Answer: A
Rationale: Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm. This provides constant monitoring given the high-risk situation.