Nokea
If a client with chronic mental illness develops the following symptoms after the physician discontinues haloperidol, which one is most likely a consequence of the drug therapy?
- A. Facial tics
- B. Depression
- C. Patchy hair loss
- D. Daytime lethargy
Correct Answer: A
Rationale: Facial tics are a potential tardive dyskinesia symptom, a known side effect of long-term haloperidol use.
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The nurse assesses the client every 15 minutes. What objective evidence will the nurse detect that indicates that the restraints are too tight? Select all that apply.
- A. The client reports being unable to move the right hand.
- B. The client's fingers and toes are pale.
- C. The client reports having pain.
- D. Capillary refill is greater than 6 seconds.
- E. There is excoriation around the wrist.
- F. The client reports numbness and tingling.
Correct Answer: B,D,F
Rationale: Pallor, prolonged capillary refill, and numbness indicate impaired circulation, suggesting restraints are too tight and compromising blood flow.
Which findings strongly suggest that the client is experiencing an exacerbation of the bipolar disorder? Select all that apply.
- A. The client has been spending money extravagantly.
- B. The client has been avoiding social activities.
- C. The client has been methodically cleaning the house.
- D. The client has been staying up late to read.
- E. The client demonstrates increased sexual promiscuity.
- F. The client has increased anxiety when going outside the house.
Correct Answer: A,E
Rationale: Extravagant spending and sexual promiscuity are indicative of mania, a key feature of bipolar disorder exacerbation.
The client with a history of aggressive behavior toward staff and peers states to the nurse “Everyone is just so touchy; I don’t see where I’m being too aggressive.” Which nursing action should be included in the therapeutic plan of care to best effect a difference in perceptions?
- A. Refamiliarize the client with the rules of the unit.
- B. Introduce nonaggressive interpersonal behaviors to the client.
- C. Promote dialogue between the staff and client to discuss the staff’s perceptions of aggressive behavior.
- D. Encourage the staff to show patience to the client because the client may have poor aggression control.
Correct Answer: C
Rationale: Dialogue (C) clarifies differing perceptions of aggression. Rules (A) or behaviors (B) are less effective without addressing perceptions and patience (D) risks safety.
The emergency department nurse describes procedures and their purposes to the rape victim before they are implemented. What is the rationale for the nurse's action?
- A. It diminishes feelings of powerlessness.
- B. It tends to reduce the client's anxiety.
- C. It is a policy of the emergency department.
- D. It meets the client's need for teaching.
Correct Answer: A
Rationale: Explaining procedures empowers the victim by restoring some control, counteracting the powerlessness experienced during the assault.
What is the most appropriate nursing action when the terminally ill client's death is imminent?
- A. Stay with the client and contact the family.
- B. Notify the hospital chaplain of the potential for death.
- C. Call the funeral home, alerting them of an imminent death.
- D. Transfer the client to the intensive care unit.
Correct Answer: A
Rationale: Staying with the client provides comfort, and contacting family ensures support, aligning with the advance directive.