Nokea
The nurse on the mental health unit is leading a group session. Shortly after the session begins, a newly admitted client with schizophrenia stands and starts to leave the room. Which of the following actions should the nurse take?
- A. In a loud, firm voice, direct the client to come back to the room
- B. Gently grasp the client's arm and redirect the client back to the seat
- C. Reinforce the unit rules and importance of attending group sessions
- D. Remain silent and allow the client to leave the room with another staff member
Correct Answer: D
Rationale: Allowing the client to leave with another staff member respects their distress and ensures safety, avoiding confrontation. Loud commands, physical redirection, or rule enforcement may escalate agitation.
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A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?
- A. An 18 month-old who ate an undetermined amount of crystal drain cleaner
- B. A 14 month-old who chewed 2 leaves of a philodendron plant
- C. A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)
- D. A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
Correct Answer: A
Rationale: An 18 month-old who ate an undetermined amount of crystal drain cleaner. Orange juice is acidic and will help neutralize the alkaline drain cleaner.
Medication administration record
Allergies: None
Medications Time
Haloperidol: 5 mg PO, twice a day 0900, 2100
Hydrochlorothiazide: 25 mg PO, daily 0900
Omeprazole: 20 mg PO, daily 0900
Acetaminophen: 650 mg PO, PRN Every 6 hours
The nurse on the inpatient psychiatric unit is preparing to administer 9 AM medications to a client. On assessment, the client is exhibiting signs of neuroleptic malignant syndrome. Which of the following actions should the nurse take?
- A. Administer acetaminophen, hold the haloperidol and reassess in 30 minutes
- B. Administer all medications, including acetaminophen, and reassess in 30 minutes
- C. Hold the haloperidol and notify the health care provider (HCP) immediately
- D. Hold the hydroxyzine and notify the HCP immediately
Correct Answer: C
Rationale: Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotics like haloperidol, requiring immediate cessation and provider notification. Acetaminophen, continuing medications, or holding hydroxyzine do not address the emergency.
A client who had a bowel resection 5 days ago says, 'I felt like I split open when I coughed.' The nurse finds the incision edges separated and bowel protruding through the wound. Which of the following actions are appropriate? Select all that apply.
- A. Administer 1 oral tablet of oxycodone prescribed PRN for pain
- B. Collect a full set of vital signs
- C. Cover the viscera with sterile dressings saturated in normal saline solution
- D. Notify the health care provider immediately
- E. Place the client in the low Fowler position with knees slightly flexed
Correct Answer: B,C,D,E
Rationale: Vital signs, sterile saline dressings, provider notification, and low Fowler with flexed knees manage dehiscence and evisceration. Oxycodone is inappropriate during this emergency.
The nurse is reinforcing teaching regarding home oxygen use for a client with emphysema who is using nasal cannula and portable oxygen tank. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I can continue to cook on my gas stove.
- B. I can use a humidifier if my nostrils feel dry.
- C. I need to keep a working fire extinguisher in my home.
- D. I should use a wool blanket on my bed instead of cotton.
- E. I can increase the oxygen flow rate whenever I feel short of breath.
Correct Answer: A,D,E
Rationale: Oxygen therapy is commonly prescribed to improve oxygenation for clients with (or at risk for) hypoxia (eg, emphysema) and to promote comfort in clients receiving palliative/hospice care. Clients requiring long-term oxygen therapy may be prescribed portable oxygen delivery (ie, home oxygen therapy) to allow increased independence in daily life.
A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The nurse should include which of the following in the priority teaching plan for the parents?
- A. Monitor respiratory rate
- B. Monitor intake and output every hour
- C. Assist the client to breathe into a paper bag
- D. Prepare to administer oxygen by mask
Correct Answer: C
Rationale: Assisting the client to breathe into a paper bag addresses hyperventilation caused by aspirin toxicity, which can lead to respiratory alkalosis in the initial stages.