Nursing Elites

1. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

• A. Dizziness when standing.
• B. Shuffling gait and hand tremors.
• C. Urinary retention.
• D. Fever of 102°F.

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

2. A male client with alcohol dependence is admitted for detoxification. The nurse knows that which assessment finding is indicative of alcohol withdrawal?

• A. Bradycardia
• B. Hypotension
• C. Tremors
• D. Hyperglycemia

Correct answer: C

Rationale: Tremors are a common sign of alcohol withdrawal. The central nervous system becomes hyperexcitable due to the suppression caused by chronic alcohol intake. Tremors are a manifestation of this hyperexcitability and are a key indicator of alcohol withdrawal. Bradycardia and hypotension are more commonly associated with conditions like shock or severe dehydration rather than alcohol withdrawal. Hyperglycemia is not a typical finding in alcohol withdrawal; instead, hypoglycemia is more commonly seen due to the effects of alcohol on glucose metabolism.

3. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.

4. A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?

• A. Ask the client to sit down and relax.
• B. Administer a PRN dose of antipsychotic medication.
• C. Encourage the client to talk about what is making him anxious.
• D. Monitor the client for adverse reactions to the medication.

Correct answer: B

Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.

5. A female client on the psychiatric unit tells the nurse that she feels like ending her life because she can no longer deal with her depression. What is the nurse's priority intervention?

• A. Stay with the client and ensure her safety.
• B. Inform the client that she is safe in the hospital.
• C. Document the client's statements in her medical record.
• D. Encourage the client to join a group therapy session.

Correct answer: A

Rationale: The correct answer is to stay with the client and ensure her safety. Ensuring the client's safety is the top priority when a client expresses suicidal ideation. Staying with the client can help prevent self-harm while further assessment and interventions are arranged. Choice B is incorrect because simply informing the client that she is safe in the hospital does not address the immediate need for safety. Choice C is incorrect as while documentation is important, it is not the priority when a client's safety is at risk. Choice D is also incorrect as encouraging the client to join a group therapy session is not appropriate when the client is in crisis and expressing suicidal thoughts.

Similar Questions