Nokea
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse implement? Select all that apply.
- A. Use distracting techniques when appropriate.
- B. Be consistently visible and available to the clients.
- C. Provide reality orientation to the clients as needed.
- D. Anticipate the needs of the clients as much as possible.
- E. Segregate potentially volatile clients from the other clients.
Correct Answer: A,B,C,D
Rationale: To maintain a safe milieu for cognitively impaired clients, the nurse should use distracting techniques to redirect inappropriate behaviors, be consistently visible and available to provide reassurance and support, provide reality orientation to help clients maintain awareness of their surroundings, and anticipate client needs to prevent distress or agitation. Segregating potentially volatile clients is not typically recommended as it may increase feelings of isolation or stigmatization; instead, managing their behavior through de-escalation and individualized care is preferred.
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A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.
Neuroleptic malignant syndrome is suspected in a client who is prescribed an atypical antipsychotic medication. Which medication should the nurse prepare in anticipation of being prescribed to treat this adverse effect related to the use of this medication?
- A. Bromocriptine
- B. Protamine sulfate
- C. Enalapril maleate
- D. Phytonadione (vitamin K)
Correct Answer: A
Rationale: Bromocriptine is a dopamine pathway medication used in the treatment of neuroleptic malignant syndrome. Protamine sulfate is the antidote for heparin overdose. Vitamin K is the antidote for warfarin overdose. Enalapril maleate is an angiotensin-converting enzyme inhibitor and an antihypertensive that is used in the treatment of hypertension.
A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
- A. Prevent atelectasis.
- B. Reduce incisional pain.
- C. Improve circulation.
- D. Promote wound healing.
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.
The nurse has an order to administer ampicillin (Omnipen) 250 mg I.M. After reconstituting the ampicillin with sterile water for injection, the solution available is 500 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL.
- B. 1 mL.
- C. 2 mL.
- D. 1.5 mL.
Correct Answer: A
Rationale: To administer 250 mg from a 500 mg/mL solution, the calculation is 250 mg / 500 mg/mL = 0.5 mL.
A client reports having pain in his casted left arm that is unrelieved by pain medication. The nurse assesses the arm and notes that the fingers are swollen and difficult to separate. Which action is most appropriate for the nurse to take at this time?
- A. Administer morphine 2 mg intravenously
- B. Apply an ice bag to the fingers to relieve pain
- C. Elevate the arm on two pillows and reassess in 30 minutes
- D. Call the physician to report swelling and pain
Correct Answer: D
Rationale: Swelling and unrelieved pain in a casted arm suggest possible compartment syndrome, requiring immediate physician notification. Elevating the arm or applying ice may help but is secondary to reporting.