Nokea
The nurse is reviewing the medications for all assigned clients on an inpatient psychiatric unit. The nurse anticipates assessing for extrapyramidal symptoms (EPS) in clients taking which antipsychotic medication?
- A. Clozapine
- B. Risperidone
- C. Haloperidol
- D. Ziprasidone
Correct Answer: C
Rationale: Haloperidol (Haldol), a conventional antipsychotic, has a high probability of causing EPS.
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The 6-month-old hospitalized with dehydration is being rehydrated with IV fluids. Which findings should indicate to the nurse that the treatment is having the desired effect? Select all that apply.
- A. Flat fontanelle
- B. Absence of crying
- C. Light yellow urine
- D. Rapid respirations
- E. Moist mucous membranes
Correct Answer: A,C,E
Rationale: A: Flat (rather than depressed) fontanelles indicate good hydration, which is the desired effect of IV rehydration. B: Absence of crying is not related to improved hydration status. C: Light-colored urine indicates good hydration, which is the desired effect of IV rehydration. D: Rapid respirations may indicate dehydration. E: Moist mucous membranes indicate good hydration, which is the desired effect of IV rehydration.
Which of the following of Erikson's developmental stages are relevant to adults ages 18-64? Select all that apply.
- A. Ego Integrity vs. Despair
- B. Generativity vs. Stagnation
- C. Industry vs. Inferiority
- D. Initiative vs. Guilt
- E. Intimacy vs. Isolation
Correct Answer: A
Rationale: In the adult 18-64 stage, Intimacy vs. Isolation is relevant to young adulthood and Generativity vs. Stagnation is relevant to middle adulthood. Initiative vs. Guilt is relevant to preschool childhood. Industry vs. Inferiority is relevant to school-age childhood. Ego Integrity vs. Despair is relevant to mature adulthood after age 65.
Ciprofloxacin is prescribed for the client to treat a UTI. Which information should the nurse stress when teaching the client about the medication?
- A. Avoid taking ciprofloxacin with dairy products such as milk or yogurt.
- B. Treat diarrhea, a side effect of ciprofloxacin, with bismuth subsalicylate.
- C. Avoid fennel because it will increase the absorption of the ciprofloxacin.
- D. Take dietary calcium tablets one hour before or two hours after ciprofloxacin.
Correct Answer: A
Rationale: A: Ciprofloxacin (Cipro) is a fluoroquinolone antibiotic. Milk or yogurt decreases its absorption and should be avoided. B: Bismuth subsalicylate decreases the absorption of ciprofloxacin and should be avoided. C: Fennel will decrease, not increase, the absorption of the ciprofloxacin. D: Dietary calcium can be taken at any time; it is unaffected by ciprofloxacin.
The HCP prescribes 5% albumin for four clients. The nurse should consult with the HCP if 5% albumin is prescribed for which client?
- A. The client of the Catholic faith who has refractory edema
- B. The African American client experiencing hypovolemic shock
- C. The client of the Jehovah's Witnesses faith who has cerebral edema
- D. The Asian client experiencing adult respiratory distress syndrome (ARDS)
Correct Answer: C
Rationale: A: Persons of the Catholic faith usually accept blood and blood products. B: Persons of African American ethnicity usually accept blood and blood products. C: Albumin is a blood derivative obtained by fractionating pooled venous and placental human plasma. Persons of the Jehovah's Witnesses faith usually do not accept RBCs; some do not accept blood products such as albumin or plasma. D: Persons of Asian ethnicity usually accept blood and blood products.
The client has been receiving clonidine 0.1 mg via transdermal patch once every 7 days. The NA removes the patch with morning cares. Eight hours later, the nurse discovers that the clonidine patch is no longer present. Which assessment finding should be most concerning to the nurse?
- A. Skin tear is noted on the client's upper chest.
- B. Client reports having an excruciating headache.
- C. Blood pressure is noted to be 182/100 mm Hg.
- D. The ECG monitor shows a heart rate of 120 bpm.
Correct Answer: C
Rationale: A: Although a skin tear is concerning and may have occurred during removal, it is not the most concerning. B: Headache can occur from the abrupt removal of clonidine but is not the most concerning. C: Clonidine (Catapres) is an antihypertensive medication. Rebound hypertension occurs from abrupt withdrawal. Immediate intervention is required to lower the BP. D: Tachycardia is an adverse effect of clonidine.