Nokea
Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication?
- A. Nausea
- B. Hypotension
- C. Blurred vision
- D. Excessive drooling
Correct Answer: D
Rationale: Adverse effects of antipsychotic medications such as haloperidol include marked drowsiness and lethargy; extrapyramidal symptoms, including parkinsonism effects (drooling); dystonias; akathisia; and tardive dyskinesia. The correct option is a parkinsonism effect of this medication, excessive drooling. Nausea, hypotension, and blurred vision are occasional side effects of the medication.
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A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
You routinely use the PQRST method to assess pain. The PQRST method consists of:
- A. Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
- B. Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers
- C. Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
- D. Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
- A. Serum potassium of 5.5 mEq/L.
- B. Serum sodium of 135 mEq/L.
- C. Hemoglobin of 12 g/dL.
- D. White blood cell count of 8,000/mm³.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
The most appropriate toys to give to a 5-month-old infant are:
- A. Plastic toy cars.
- B. Wooden puzzles.
- C. Stuffed animals.
- D. Soft, washable toys.
Correct Answer: D
Rationale: Soft, washable toys are safe and appropriate for a 5-month-old, who explores through touch and mouthing. Toy cars and puzzles are choking hazards, and stuffed animals may pose hygiene risks.
The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which of the following?
- A. Use of protective goggles during a cesarean delivery.
- B. Placement of bloody sheets in a container designated for contaminated linens.
- C. Wearing of sterile gloves to bathe a newly delivered neonate at 1 hour of age.
- D. Disposal of used scalpel blades in a puncture-resistant container.
Correct Answer: C
Rationale: Sterile gloves are unnecessary for bathing a neonate; clean gloves suffice, indicating a need for further instruction on standard precautions.