Nokea
The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regards to tardive dyskinesia?
- A. TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30
- B. It can occur in clients taking antipsychotic drugs longer than 2 years
- C. Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible
- D. TD can easily be treated with anticholinergic drugs
Correct Answer: B
Rationale: Tardive dyskinesia is an extrapyramidal side effect that typically develops after prolonged use of antipsychotic drugs, often longer than 2 years, and is not easily reversible or treated with anticholinergics.
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A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Positioning the patient with the head of the bed elevated 60°-90° (high Fowler’s position) facilitates swallowing and allows gravity to aid the passage of the nasogastric (NG) tube through the esophagus into the stomach. This position reduces the risk of aspiration and eases tube insertion. Lower elevations (30°-45°), side-lying, or flat positions do not optimize swallowing or tube advancement as effectively.
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
- A. Decreased level of consciousness (LOC)
- B. Elevated blood pressure
- C. Increased urine output
- D. Decreased heart rate
Correct Answer: C
Rationale: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
What would be the nurse's response?
- A. Decrease cardiac output.
- B. Increase cardiac output.
- C. Decrease cardiac contractility.
- D. Increase cardiac contractility.
Correct Answer: C
Rationale: Beta-blockers decrease heart rate and cardiac contractility, reducing myocardial oxygen demand and relieving angina.
A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?
- A. I should make sure he gets plenty of rest.'
- B. I should get him a medic alert bracelet.'
- C. I should lay him on his back during a seizure.'
- D. I should loosen his clothing during a seizure.'
Correct Answer: C
Rationale: Laying a seizing child on their back risks aspiration; the correct position is on the side. The other statements reflect appropriate seizure management. Reduction of Risk Potential
The pathophysiology of anaphylaxis is
- A. It is treated with adrenalin or epinephrine.
- B. A severe vasoconstriction and profound bronchodilation.
- C. Characterized by presence of rashes all throughout the body.
- D. A profound hypotension due to profound vasodilation and severe bronchoconstriction.
Correct Answer: D
Rationale: Anaphylaxis involves vasodilation and bronchoconstriction, leading to hypotension and respiratory distress.