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Questions 149

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Question 1 of 5

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Correct Answer: D

Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.

Question 2 of 5

A labor and delivery nurse is caring for a newborn baby whose mother was a regular cocaine user during the entire pregnancy (prenatal cocaine exposure). The nurse expects the newborn to

Correct Answer: A

Rationale: Prenatal cocaine exposure causes neonatal irritability, sleep disturbances, and a shrill cry due to central nervous system stimulation.

Question 3 of 5

The nurse is doing hourly rounds when he finds a 73-year-old female client unconscious on the floor next to the bed. An incident report must be filled out. What is the best statement for the nurse to write on the incident report?

Correct Answer: B

Rationale: The incident report should state objective findings: 'Client was found unresponsive on floor next to the bed.' Speculative statements (slipped, attempted to ambulate) are inappropriate.

Question 4 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.

Question 5 of 5

The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been ineffective?

Correct Answer: D

Rationale: Spinach is high in purines, which can exacerbate gout. Cabbage, apples, and peach cobbler (if low in purine ingredients) are suitable for a low-purine diet.

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