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The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?
- A. Monitor vital signs every 15 minutes.
- B. Administer bromocriptine as prescribed.
- C. Administer the haloperidol as prescribed.
- D. Assess the client's level of consciousness.
Correct Answer: B
Rationale: The symptoms suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to haloperidol. Administering bromocriptine, if prescribed, is the priority to reverse NMS. Monitoring, continuing haloperidol, or assessing consciousness delays critical intervention.
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A client is demonstrating confusion as a result of bed rest and a prolonged length of hospital stay. The client receives a prescription for progressive ambulation as tolerated. Which is the best nursing intervention to use to implement the prescription?
- A. Ambulate to the client's bathroom three times a day.
- B. Ambulate in the room for short distances frequently.
- C. Ambulate in the hall progressively three times a day.
- D. Assist with range-of-motion exercises three times a day.
Correct Answer: C
Rationale: The cause of the client's confusion is bed rest and decreased sensory stimulation from a prolonged length of stay; therefore, the best intervention is to ambulate the client in the hall to increase sensory stimulation. Hopefully the stimulation can help decrease the confusion. Options 1 and 2 do not address the client's need for sensory stimulation. The nurse performs option 4 in preparation for ambulation while the client is on bed rest.
A client who is receiving total parenteral nutrition (TPN) tells the nurse, 'I'm not sure that I want to receive an infusion of lipids because it could make me obese.' Which initial action should the nurse take?
- A. Inquire how illness affects the client's self-concept.
- B. Ask the provider to discuss the benefits of intralipids.
- C. State that intralipids supply essential fatty acids for life.
- D. Explain how intralipids replace dietary sources of lipids.
Correct Answer: A
Rationale: A client who receives TPN is at risk for developing an essential fatty acid deficiency; however, this client's comment requires more than a simple informational response initially. Thus, the nurse responds with option 1 to assist the client with self-expression and to deal with aspects of illness and treatment. Option 2 delays client self-expression and devalues the client's feelings. Options 3 and 4 provide information only.
A preschool child is placed in traction for a femur fracture. The child has started bedwetting, even though the child has been toilet trained for a year. The mother is very upset about the situation. The nurse explains to the mother that this behavior should be recognized as which psychosocial adaptation?
- A. A body image disturbance
- B. Attention-seeking behavior
- C. Opposition to authority figures
- D. Regressing to earlier developmental behavior
Correct Answer: D
Rationale: The monotony of immobilization can lead to sluggish intellectual and psychomotor responses. Regressive behaviors are not uncommon in immobilized children, and they usually do not require professional intervention. Body image may or may not be affected by long-term immobilization, but it does not relate to the information presented in the question. The remaining options are not relevant to the described situation.
A client recovering from a diagnosed head injury becomes agitated at times. Which nursing action is most appropriate when attempting to calm this client?
- A. Assign the client a new task to master.
- B. Turn on the television to a musical program.
- C. Make the client aware that the behavior is undesirable.
- D. Talk about the family pictures on display in the client's room.
Correct Answer: D
Rationale: Providing familiar objects will decrease anxiety. Decreasing environmental stimuli also aids in reducing agitation for the head-injured client. Option 1 does not simplify the environment because a new task may be frustrating. Option 2 increases stimuli. In option 3 the nurse uses negative reinforcement to help the client adjust.
A client states to the nurse, 'I don't do anything right. I'm such a loser.' Which therapeutic statement should the nurse make to the client?
- A. You don't do anything right?
- B. You do things right all the time.
- C. Can we identify things you do right?
- D. You are not a loser, you are depressed.
Correct Answer: A
Rationale: Option 1 provides the client with the opportunity to verbalize. With this statement, the nurse can learn more about what the client really means by the statement. The remaining options are closed statements and do not encourage the client to explore further.