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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?
- A. Cramping muscular pain
- B. Worming movements of the tongue
- C. Decreased tendon reflexes
- D. Dry oral mucous membranes
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. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Ensure that the knot can be quickly released.
- B. Tie the knot with a double turn or square knot.
- C. Move the ties so the restraints are secured to the side rails.
- D. Ensure that the restraints are snug against the client's wrist.
Correct answer: A
Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.
3. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?
- A. Do not read with direct lighting for 6 weeks
- B. Avoid straining during stool passage, bending, or lifting heavy objects
- C. Irrigate conjunctiva with ophthalmic saline after applying antibiotic ointment
- D. Limit exposure to sunlight during the first 2 weeks while the cornea is healing
Correct answer: B
Rationale: The correct instruction to include in the discharge teaching for a client following cataract extraction is to 'Avoid straining during stool passage, bending, or lifting heavy objects.' This is crucial to prevent increased intraocular pressure after surgery, which can be harmful. Reading with direct lighting can strain the eyes but is not the primary concern post-cataract surgery. Irrigating the conjunctiva before applying antibiotic ointment is not a standard practice and may not be necessary. While limiting sunlight exposure is important for eye protection, it is secondary to avoiding activities that can increase intraocular pressure.
4. The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?
- A. Inability to touch their toes
- B. Asymmetry of the shoulders when standing upright
- C. Audible crepitus when bending
- D. An exaggerated upper thoracic convex curvature
Correct answer: B
Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.
5. When should the nurse conduct an Allen’s test?
- A. When obtaining pulmonary artery pressures
- B. To assess for the presence of a deep vein thrombus in the leg
- C. Just before arterial blood gases are drawn peripherally
- D. Prior to attempting a cardiac output calculation
Correct answer: C
Rationale: The correct time to conduct an Allen’s test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen’s test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen’s test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen’s test is not done specifically before attempting a cardiac output calculation.
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