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When the nurse documents this incident, which wording is most appropriate?
- A. Became angry for no reason and an assault occurred.
- B. Hit caregiver unexpectedly even though not provoked.
- C. Struck nursing assistant when being helped from bed.
- D. Attacked nursing assistant without prior warning.
Correct Answer: C
Rationale: Objective language like 'struck' accurately describes the incident without bias.
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Which nursing instruction is most appropriate when teaching a client who self-administers haloperidol (Haldol)?
- A. Take the pills on an empty stomach.
- B. Do not skip meals while taking the drug.
- C. Stop taking the drug if sedation occurs.
- D. Rise slowly from a sitting position.
Correct Answer: D
Rationale: Rising slowly prevents orthostatic hypotension, a common side effect.
When the parents ask about the side effects of taking methylphenidate hydrochloride (Ritalin), the nurse correctly explains that the child may have which common cluster of signs and symptoms?
- A. Nausea, vomiting, and diarrhea
- B. Fatigue, drowsiness, and dry mouth
- C. Insomnia, tachycardia, and anorexia
- D. Hypotension, bradycardia, and constipation
Correct Answer: C
Rationale: Insomnia, tachycardia, and anorexia are common side effects of Ritalin.
If and when the autistic child actually makes an effort to self-feed, which of the following suggestions is most appropriate for the nurse to make?
- A. Note if the self-feeding effort is repeated.
- B. Stop feeding the child thereafter.
- C. Demonstrate approval in some way.
- D. Offer food more frequently during the day.
Correct Answer: C
Rationale: Positive reinforcement encourages repetition of desired behaviors.
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 adolescent is typical of others who have grown up in an alcoholic family, the nurse would expect to assess for problems in which area?
- A. Low self-esteem
- B. Managing stress
- C. Long-term learning
- D. Fear of authority
Correct Answer: A
Rationale: Low self-esteem is common in children of alcoholics due to unpredictable environments.