a male client with schizophrenia is jerking his neck and smacking his lips which finding indicates to the nurse that he is experiencing an irreversibl
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1. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?

Correct answer: B

Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.

2. A child with heart failure (HF) is taking digitalis. Which sign indicates to the nurse that the child may be experiencing digitalis toxicity?

Correct answer: C

Rationale: Vomiting is a common sign of digitalis toxicity and should be closely monitored. While tachycardia is a common sign of heart failure, it is not typically associated with digitalis toxicity (Choice A). Dyspnea (Choice B) and muscle cramps (Choice D) are not specific signs of digitalis toxicity and can be present in other conditions. Therefore, the presence of vomiting should raise concerns about digitalis toxicity in the child with heart failure.

3. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

Correct answer: D

Rationale: Imbalanced nutrition is the priority in this case as the patient has lost a significant amount of weight and is neglecting self-care, such as bathing and eating properly. The weight loss indicates a serious issue that needs immediate attention to prevent further health complications. While self-care deficit, disturbed sleep pattern, and disturbed thought processes are also concerns for this patient, addressing the imbalanced nutrition takes precedence due to the potential impact on the patient's physical health. Neglecting proper nutrition can lead to serious complications, so it is crucial to address this issue first.

4. Where should the nurse choose as the best location to begin a screening program for hypothyroidism?

Correct answer: B

Rationale: The best location for beginning a screening program for hypothyroidism would be an African-American senior citizens center. This choice is the most suitable as hypothyroidism is more prevalent among older adults, and African-American seniors are at a higher risk for this condition due to various factors like genetics and lifestyle. Choices A, C, and D are less appropriate because hypothyroidism is not specifically linked to business and professional women, Hispanic children, or Native-American teens. Targeting the high-risk group, which in this case, are African-American seniors, increases the chances of successful screening and early detection.

5. The charge nurse of a cardiac telemetry unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client should be assigned to the RN?

Correct answer: D

Rationale: The correct answer is D because complete heart block is a critical condition that requires immediate assessment and management by a registered nurse (RN). In complete heart block, there is a significant conduction disturbance that can lead to serious complications. The RN is better equipped to handle such complex and potentially life-threatening situations. Choices A, B, and C involve less critical conditions that can be managed by a practical nurse (PN) under the supervision of the RN. Therefore, assigning the client with complete heart block to the RN ensures prompt and appropriate intervention.

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