Nokea
The LPN is admitting a client to the unit, and the client has rapidly blinking eyes, a stuck-out tongue, and a distorted posture. Which of these medications is the client most likely taking?
- A. Clozapine
- B. Fluoxetine
- C. Ondansetron
- D. Haloperidol
Correct Answer: D
Rationale: The correct answer is Haloperidol. Haloperidol is a first-generation antipsychotic that blocks dopamine receptors and is most likely to cause extrapyramidal symptoms (EPS), such as tardive dyskinesia. Symptoms of tardive dyskinesia include rapid blinking, mouth movements, sticking out the tongue, rapid body movements, and a distorted posture. Haloperidol is associated with a higher risk of EPS compared to other antipsychotic medications like Clozapine. Clozapine is known for having a lower risk of causing EPS. Fluoxetine is a selective serotonin reuptake inhibitor used for depression and anxiety, not typically associated with these movement disorder symptoms. Ondansetron is an antiemetic used to prevent nausea and vomiting, not linked to these extrapyramidal symptoms.
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The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?
- A. slow speech development
- B. overreaction to stimuli from the surroundings
- C. inability to carry on a conversation
- D. concrete thinking
Correct Answer: B
Rationale: The correct answer is 'overreaction to stimuli from the surroundings.' Children with attention deficit disorder often exhibit hypersensitivity to stimuli, leading to overreactions. Slow speech development is not a hallmark of attention deficit disorder; it is more associated with other learning disabilities. While children with this disorder may have difficulty focusing, they can usually carry on a conversation. Concrete thinking is not a common characteristic of attention deficit disorder, as individuals with this disorder may struggle with abstract thinking and impulsivity.
The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?
- A. "I will hold my breath for 10 seconds after each puff."?
- B. "I will wait five minutes after taking this medication and then gargle water."?
- C. "I will wait at least one minute between each puff."?
- D. "I will take this medication daily even if I am not having symptoms."?
Correct Answer: B
Rationale: The correct answer is, 'I will wait five minutes after taking this medication and then gargle water.' After using an inhaled glucocorticoid, it is essential to wait for 5 minutes and then gargle water to remove any residue from the mouth, which can reduce the risk of developing thrush, a fungal infection. Choice A is correct as holding the breath for 10 seconds after each puff helps the medication reach deep into the lungs. Choice C is also correct as waiting at least one minute between puffs ensures proper delivery of the medication. Choice D is incorrect because it is important to take the medication daily as prescribed to control asthma symptoms, even if the person is not experiencing any at that moment.
A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm, and the color is pink. What action should the nurse perform next to prevent ischemia?
- A. Notify the physician immediately
- B. Obtain a Doppler device to check for pulses, and notify the physician if they are still absent
- C. Wait 30 minutes and recheck the pulses
- D. Document the finding
Correct Answer: B
Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial pulses can be difficult to assess and might need to be verified with a Doppler device. Since the client just had surgery with a risk of arterial insufficiency, close monitoring is crucial. If pulses are not palpable, it indicates an emergent situation requiring immediate physician notification. Waiting 30 minutes before reassessment could lead to foot ischemia. While documenting findings is essential, it should follow pulse confirmation or necessary interventions to ensure the client's foot viability.
Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?
- A. Liver
- B. Spleen
- C. Pancreas
- D. Appendix
Correct Answer: D
Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.
The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?
- A. I'm worried that my child is not using two-word phrases yet.
- B. My child has recently taken a few steps but does not seem stable when standing.
- C. My child seems to have developed separation anxiety when I leave.
- D. I'm letting my child use a spoon to eat.
Correct Answer: B
Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.