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The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior?
- A. Muscle rigidity and shuffling gait
- B. Nihilistic delusions
- C. Tangential speech
- D. Waxy flexibility
Correct Answer: A
Rationale: Benztropine is an anticholinergic used to treat extrapyramidal symptoms (EPS), such as muscle rigidity and shuffling gait, which are side effects of antipsychotics like haloperidol.
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The nurse is reinforcing teaching for a client who has a new prescription for levothyroxine. Which of the following information should the nurse reinforce?
- A. Discontinue the medication if you become pregnant.
- B. Take the medication at bedtime to decrease drowsiness.
- C. Notify your health care provider if you experience palpitations.
- D. Take the medication with a snack if you experience an upset stomach.
Correct Answer: C
Rationale: Palpitations may indicate levothyroxine overdose or hyperthyroidism, requiring prompt reporting to adjust the dose or evaluate thyroid function.
A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted?
- A. Improvement in short-term memory
- B. Improvement in spontaneous activity
- C. Reduction in number of visual hallucinations
- D. Reduction of dizziness with standing
Correct Answer: B
Rationale: Carbidopa-levodopa treats Parkinson's symptoms like bradykinesia, improving spontaneous activity, which is the primary therapeutic goal.
The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?
- A. Vancomycin trough 10 mg/L (6.9 umol/L), creatinine 1.1 mg/dL (97.2 umol/L), BUN 6 mg/dL (2.1 mmol/L)
- B. Vancomycin trough 14 mg/L (9.7 umol/L), creatinine 1.2 mg/dL (106.1 umol/L), BUN 10 mg/dL (3.6 mmol/L)
- C. Vancomycin trough 18 mg/L (12.4 umol/L), creatinine 0.6 mg/dL (53 umol/L), BUN 18 mg/dL (6.4 mmol/L)
- D. Vancomycin trough 23 mg/L (15.9 umol/L), creatinine 1.5 mg/dL (132.6 umol/L), BUN 24 mg/dL (8.6 mmol/L)
Correct Answer: D
Rationale: A vancomycin trough of 23 mg/L is above the therapeutic range (10-20 mg/L), indicating potential toxicity. Elevated creatinine (1.5 mg/dL) suggests renal impairment, which increases the risk of vancomycin accumulation and nephrotoxicity.
The nurse is caring for a client who experienced a sexual assault and has posttraumatic stress disorder. The client states, 'It is all my fault. I should not have accepted a drink from a stranger I met at a bar.' Which of the following responses would be most appropriate for the nurse to make?
- A. Those thoughts are not good for you. You should try to stop thinking about the assault.
- B. You have to stop blaming yourself for the assault so you can move on with your life.
- C. It may take time to overcome your thoughts and feelings related to the assault.
- D. You could not have anticipated the assault. You did not deserve or ask for it.
Correct Answer: D
Rationale: This response validates the client's feelings while gently correcting self-blame, reinforcing that the assault was not their fault and promoting a supportive therapeutic environment.
The nurse prepares to reinforce teaching for a client with latent tuberculosis who is prescribed oral isoniazid. Which instructions should the nurse include? Select all that apply.
- A. Avoid drinking alcohol
- B. Expect body fluids to change color to red
- C. Report yellowing of skin or sclera
- D. Report numbness and tingling of extremities
- E. Take with aluminum hydroxide to prevent gastric irritation
Correct Answer: A,C,D
Rationale: Avoiding alcohol (A), reporting jaundice (C), and reporting neuropathy (D) address isoniazid's risks of hepatotoxicity and peripheral neuropathy.