Nokea
An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room.
- A. What is the most important nursing intervention for a client receiving haloperidol IM every 30 minutes?
- B. Monitor vital signs, especially blood pressure, every 30 minutes.
- C. Remain at the client’s side to provide reassurance.
- D. Tell the client the name of the medication and its effects.
- E. Monitor the anticholinergic effects of the medication.
Correct Answer: A
Rationale: Haloperidol can cause postural hypotension due to alpha-adrenergic blockade, especially during rapid neuroleptization. Monitoring vital signs, particularly blood pressure, every 30 minutes ensures client safety. Reassurance, education, and monitoring side effects are secondary to physiological stability.
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A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
- A. Regulate the neonate's temperature using a radiant heater
- B. Withhold feedings while under the phototherapy
- C. Provide water feedings at least every 2 hours
- D. Protect the eyes of neonate from the phototherapy lights
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
The nurse is to insert an indwelling catheter in a male. Which action is appropriate?
- A. Cleanse the meatus before preparing the catheter for insertion
- B. Wash hands before starting the procedure
- C. Hold the penis at a 45-degree angle during insertion of the catheter
- D. Inflate the balloon immediately before inserting the catheter
Correct Answer: B
Rationale: Washing hands before catheter insertion is critical to maintain a sterile field and prevent infection. Cleansing the meatus occurs after hand washing, a 45-degree angle is incorrect (90 degrees is typical), and the balloon is inflated post-insertion.
A client with pernicious anemia is admitted. What would the nurse expect the admitting assessment to reveal?
- A. Ecchymoses on the trunk
- B. Bilateral neuropathy of the legs
- C. Decreased platelet count
- D. Decreased appetite
Correct Answer: B
Rationale: Pernicious anemia, a vitamin B12 deficiency, often causes neurological symptoms like bilateral leg neuropathy due to nerve demyelination.
The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
- A. confront the staff member immediately and say, 'You know that is not the treatment plan.'
- B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
- C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
- D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct Answer: C
Rationale: It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff.
An older woman hospitalized with a fractured left hip, placed in Buck's traction with a seven-pound weight while awaiting surgery.
Which of the following instructions for moving should be discussed by the nurse to encourage the patient to participate in her care?
- A. Pull up on the overhead trapeze while you push down on your right foot to lift your body.'
- B. With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently.'
- C. I'll raise the head of the bed 45°, and then you lean forward and rotate your hips to the left.'
- D. Swing your right leg over your left leg, and turn from your waist down, keeping your legs straight.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side, can only move up and down