Nokea
An elderly man diagnosed with chronic schizophrenia is being followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and has recently developed symptoms of tardive dyskinesia.
The nurse's documentation on this client should include
- A. assessment of ADL (self-care) ability.
- B. Mini-Mental Status Examination (MMSE).
- C. Abnormal Involuntary Movement Scale (AIMS).
- D. Modified Overt Aggression Scale (MOAS).
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) assessment of client's abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill (2) measures cognitive function (3) correct-is most widely accepted examination to Test for the presence of tardive dyskinesia (4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population
You may also like to solve these questions
The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask?
- A. Did you have anything to eat or drink before you came in today?
- B. Have you had any headaches since your last treatment?
- C. Who came with you to the hospital today?
- D. Have you had much memory loss since you began your treatments?
Correct Answer: A
Rationale: client given general anesthesia for ECT; NPO after midnight
The nurse is caring for clients in the skilled nursing facility.
- A. Which client requires the nurse’s immediate attention?
- B. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago.
- C. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine.
- D. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
- E. An immunosuppressed client who has not received an influenza immunization.
Correct Answer: A
Rationale: A client with an expired warfarin prescription post-CVA is at high risk for recurrent stroke due to the anticoagulant’s 2-5 day duration, requiring immediate attention. Pain management, urinary symptoms, and immunization are less urgent.
A client has an order for a low-sodium, low-cholesterol diet. The nurse knows that which of the following selections reflects the client's compliance?
- A. Canned vegetable soup, applesauce, and hot chocolate.
- B. Cheeseburger, french fries, and skim milk.
- C. Tomato and lettuce salad, roasted chicken, and lemonade.
- D. Tuna fish sandwich, cottage cheese, and a cola.
Correct Answer: C
Rationale: fresh fruits and vegetables are low sodium, roasted chicken is low cholesterol
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 2,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³. Which of the following nursing diagnoses is MOST appropriate for this patient?
- A. Decreased cardiac output.
- B. Ineffective thermoregulation.
- C. Risk for injury.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: due to low platelet count, normal platelets 150,000-400,000/mm³, decrease causes problems with blood clotting
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have pain in my upper abdomen.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Upper abdominal pain may indicate pancreatitis, a rare but serious side effect of sitagliptin, requiring immediate evaluation. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with breakfast is acceptable.