a client is diagnosed with schizophrenia a physician orders haloperidol haldol 50 mg bid benztropine cogentin 1 mg prn and zolpidem ambien 10 mg hs wh

NCLEX-RN

NCLEX RN Exam Review Answers

1. A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

A. Tactile hallucinations
B. Tardive dyskinesia
C. Restlessness and muscle rigidity
D. Reports of hearing disturbing voices

Correct answer: C

Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms, such as restlessness and muscle rigidity, which are common side effects of antipsychotic medications like haloperidol. Tactile hallucinations and reports of hearing disturbing voices are symptoms of schizophrenia that would typically be addressed by the antipsychotic medication (haloperidol) itself. Tardive dyskinesia, a potential side effect of long-term antipsychotic use, would require discontinuation of the antipsychotic medication rather than administration of benztropine.

2. As a nurse, you have been assigned to take over as charge nurse without any report after the previous charge nurse fell during her shift and was taken to the emergency room. At the end of the shift, you have made the assignments for the next shift's nurses and posted them. As the nurses come in, they begin to complain that the assignments make no sense based on patient acuity. One refuses to take her assignment and threatens to go home. What could you have done to prevent their dissatisfaction?

A. Reviewed the notes of the previous charge nurse
B. Tried to contact the previous charge nurse in the emergency room
C. Collaborated with the nurse manager
D. Collaborated with the other nurses on your shift

Correct answer: D

Rationale: Collaborating with the other nurses on your shift would have permitted them to provide the most updated information regarding patient status and acuity. Requesting their input into creating assignments would have provided shared governance and assurance that the unit staffing was arranged appropriately. Reviewing the notes of the previous charge nurse might not capture the real-time changes in patient conditions. Trying to contact the previous charge nurse in the emergency room may not be feasible or timely. Collaborating with the nurse manager could be helpful, but involving the nurses directly impacted by the assignments would have been more effective in addressing their concerns and ensuring appropriate patient care.

3. A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?

A. The registered nurse will be performing the procedure
B. The procedure takes approximately 1 ? hours.
C. The nurse will draw out 250cc of blood and then immediately replace it with 250cc
D. The infant will continue to receive phototherapy during the procedure.

Correct answer: B

Rationale:

4. The priority goal for a family who practices Chinese medicine would be to:

A. Achieve harmony
B. Maintain a balance of energy
C. Respect life
D. Restore yin and yang

Correct answer: D

Rationale: In Chinese medicine, the concept of yin and yang represents the balance of opposing forces in the body. When there is an imbalance between yin and yang, it can result in illness. Therefore, the priority goal for a family practicing Chinese medicine would be to restore the harmony and balance between yin and yang. Choices A, B, and C are not the priority goal in Chinese medicine. While achieving harmony, maintaining a balance of energy, and respecting life are important aspects of Chinese medicine, the fundamental principle revolves around maintaining the equilibrium of yin and yang for optimal health.

5. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?

A. Torticollis, with shortening of the sternocleidomastoid muscle
B. Craniosynostosis, with premature closure of the cranial sutures
C. Plagiocephaly, with flattening of one side of the head
D. Hydrocephalus, with increased head size

Correct answer: A

Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.