Nokea
When the client calls the nurse to report the following physical changes, which symptom is considered a serious side effect of clozapine that needs to be reported immediately to the prescribing physician?
- A. Frequent diarrhea
- B. Severe sore throat
- C. Gradual weight loss
- D. Ringing of the ears
Correct Answer: B
Rationale: Severe sore throat may indicate agranulocytosis, a life-threatening side effect of clozapine.
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Which of the following are behavioral effects of anabolic steroids?
- A. Aggression and rage
- B. Confusion and doubt
- C. Anxiety and depression
- D. Paranoia and suicidal ideation
Correct Answer: A
Rationale: Aggression and rage are well-documented effects of steroid use.
On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.
What advice is most appropriate to give the parents at this time?
- A. Tell the parents to disregard their son's behavior; it is normal grieving.
- B. Advise the parents to tell their son to snap out of it; his life is not over.
- C. Suggest transferring their son to another school.
- D. Advise the parents to ask their son about having thoughts of suicide.
Correct Answer: D
Rationale: Directly addressing suicidal thoughts is critical for safety.
When planning care for an autistic child, which nursing intervention is most appropriate?
- A. Providing interactive play activities
- B. Applying soft restraints while in bed
- C. Using a consistent caregiver
- D. Rocking the child as a calming technique
Correct Answer: C
Rationale: Consistency reduces anxiety in autistic children.
If the mother asks the nurse how to appropriately discipline a child of this age, which response by the nurse is most appropriate?
- A. By identifying the consequences of unacceptable behavior to the nurse.
- B. By showing disapproval immediately after an unacceptable act
- C. By administering some form of moderate physical punishment
- D. By explaining to the toddler why certain behavior is undesirable
Correct Answer: B
Rationale: Immediate disapproval helps toddlers associate behavior with consequences.