Nokea
Besides involuntary tremors, which other side effect should the nurse advise the family to anticipate?
- A. Muscle weakness
- B. Muscle atrophy
- C. Muscle contractures
- D. None of the above
Correct Answer: A
Rationale: Haloperidol can cause extrapyramidal symptoms, including muscle weakness.
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What advice is most appropriate to give the parents at this time?
- A. Tell the parents to disregard their son's behavior; it is normal grieving.
- B. Advise the parents to tell their son to snap out of it; his life is not over.
- C. Suggest transferring their son to another school.
- D. Advise the parents to ask their son about having thoughts of suicide.
Correct Answer: D
Rationale: Directly addressing suicidal thoughts is critical for safety.
During the nursing assessment, which of the following suggests that the mother may be continuing to abuse heroin?
- A. The mother states, 'I am tired all the time and find myself needing to sleep when the baby sleeps.'
- B. The nurse notes a variety of small ecchymotic areas on the arms and legs of the mother.
- C. The mother appears indifferent to the crying of the newborn.
- D. The mother has a body odor and the newborn appears unkempt.
- E. The mother expresses an inability to afford public transportation to the clinic.
- F. The mother states that the father of the child is no longer associated with the family.
Correct Answer: B,C,D
Rationale: Ecchymotic areas suggest injection sites, indifference may indicate substance use, and poor hygiene is a common sign of ongoing abuse.
Which response by the nurse provides the best explanation of the child's behavior?
- A. Thumb sucking is a primitive form of self-stimulation and security.
- B. Thumb sucking is a regressive behavior with a comforting effect.
- C. Thumb sucking substitutes for the missing fluids due to postoperative restriction of fluids.
- D. Thumb sucking satisfies the child's increased need for a familiar touch.
Correct Answer: B
Rationale: Thumb sucking is a regressive behavior triggered by stress, offering comfort.
Which assessment finding differentiates bulimia from anorexia nervosa in an adolescent with a suspected eating disorder?
- A. Body image distortion
- B. Purging after meals
- C. Decreased self-esteem
- D. Binge eating
Correct Answer: B
Rationale: Purging after meals is characteristic of bulimia, not always present in anorexia.
Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.