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The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth.
- B. Mild sedation.
- C. Muscle stiffness and tremors.
- D. Insomnia.
Correct Answer: C
Rationale: Muscle stiffness and tremors suggest extrapyramidal symptoms, a serious haloperidol side effect. Options A, B, and D are less urgent.
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The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?
- A. The client should be told to breathe normally.
- B. The client should be told to take two or three deep breaths as the drain is being removed.
- C. The client should be told to hold his breath as the drain is being removed.
- D. The client should breathe slowly as the drain is being removed.
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.
A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:
- A. Slow pulse, weight loss, diarrhea, and cardiac failure
- B. Weight gain, lethargy, slowed speech, and decreased respiratory rate
- C. Rapid pulse, constipation, and bulging eyes
- D. Decreased body temperature, weight loss, and increased respiratory rate
Correct Answer: B
Rationale: Myxedema (severe hypothyroidism) causes weight gain, lethargy, slowed speech, and decreased respiratory rate due to slowed metabolism. Other options describe hyperthyroidism or mixed symptoms.
The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients?
- A. A patient with a chest tube who is ambulating in the hall.
- B. A patient with a colostomy who requires assistance with an irrigation.
- C. A patient with a right-sided cerebral vascular accident (CVA) who requires assistance with bathing.
- D. A patient who is refusing medication to treat cancer of the colon.
Correct Answer: D
Rationale: requires assessment skills of the RN
The nurse is caring for a client with a history of ulcerative colitis.
- A. Which laboratory finding is most concerning for a client with ulcerative colitis?
- B. Hemoglobin of 10.5 g/dL.
- C. White blood cell count of 15,000/mm³.
- D. Serum potassium of 3.8 mEq/L.
- E. Albumin of 3.0 g/dL.
Correct Answer: B
Rationale: A white blood cell count of 15,000/mm³ suggests infection or severe inflammation in ulcerative colitis, requiring immediate attention. Low hemoglobin and albumin are common, and normal potassium is unremarkable.
A baby girl is born with a meningomyelocele. To prevent trauma to the sac, the nurse should place the infant:
- A. Supine and flat
- B. Prone with the hips slightly elevated
- C. Prone with the head slightly elevated
- D. Side lying
Correct Answer: B
Rationale: Placing the infant prone with hips slightly elevated protects the meningomyelocele sac from trauma and pressure.