Nokea
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 client statements would be of GREATest concern to the nurse?
- A. I feel stiff when I walk.
- B. I have a dry mouth.
- C. I feel sleepy in the afternoon.
- D. I have a headache sometimes.
Correct Answer: A
Rationale: Stiffness when walking suggests extrapyramidal symptoms (EPS), a serious side effect of haloperidol, requiring evaluation for possible dose adjustment or antiparkinsonian medication. Options B, C, and D are common, less urgent side effects: dry mouth, sedation, and headaches.
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The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
- A. Pointing out inconsistencies in speech patterns to correct thought disorders
- B. Accepting client and the client's behavior unconditionally
- C. Encouraging dependency in order to develop ego controls
- D. Consistent limit-setting enforced 24 hours per day
Correct Answer: D
Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.
A 32-year-old man comes to the clinic for a glycosylated hemoglobin assay (HbA1c). The result is 6%. The nurse should
- A. document the findings in the chart.
- B. call the physician about orders to adjust the insulin dosage.
- C. give him 15 g of carbohydrates.
- D. ask him to list the foods he has eaten in the last 24 hours.
Correct Answer: A
Rationale: An HbA1c of 6% indicates good diabetes control (normal 4–6%). Documenting is appropriate as no action is needed. Options B, C, and D are unnecessary.
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
- A. An adolescent taking medications for acne
- B. An elderly client living in a retirement center taking prednisone
- C. A young adult in the second trimester of pregnancy
- D. A middle-aged client receiving radiation for throat cancer
Correct Answer: D
Rationale: A middle-aged client receiving radiation for throat cancer. Radiation therapy, particularly to the abdomen or pelvis, can disrupt the gut microbiota and increase the risk of C. difficile infection, especially if the client is also receiving antibiotics or has a weakened immune system.
The nurse observes that a child with muscular dystrophy has a positive Gower's sign. The nurse documents that the child:
- A. Has weak deep tendon reflexes
- B. Must use his hands to rise from the floor
- C. Has increased spinal reflexes
- D. Rocks back and forth in rhythmical fashion
Correct Answer: B
Rationale: A positive Gower's sign indicates the child uses their hands to push up from the floor due to muscle weakness, so B is correct. Answers A, C, and D do not describe Gower's sign.
The nurse is caring for a client with a history of diabetic ketoacidosis.
- A. Which intervention is most important for a client with diabetic ketoacidosis?
- B. Administer insulin as ordered.
- C. Restrict all oral fluids.
- D. Administer oral glucose.
- E. Monitor blood pressure every 4 hours.
Correct Answer: A
Rationale: Insulin administration corrects hyperglycemia and ketosis in diabetic ketoacidosis, the primary treatment. IV fluids are used, oral glucose is contraindicated, and blood pressure monitoring is less frequent.