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Questions 164

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Question 1 of 5

At the geriatric day care program a client is crying and repeating 'I want to go home. Call my daddy to come for me.' The nurse should

Correct Answer: C

Rationale: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits. This uses comforting and distraction to reduce distress in dementia.

Question 2 of 5

The nurse is caring for an adult male who is receiving haloperidol (Haldol). Which complaint by the client is of most concern to the nurse and should be immediately reported?

Correct Answer: C

Rationale: Leg cramping and restlessness suggest akathisia, a serious extrapyramidal side effect of haloperidol, requiring immediate reporting.

Question 3 of 5

The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, HPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?

Correct Answer: A

Rationale: The majority of reactions occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.

Question 4 of 5

The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?

Correct Answer: C

Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.

Question 5 of 5

Which of the following beverages is most appropriate for a client with renal failure?

Correct Answer: C

Rationale: Apple juice is most appropriate for a client with renalrape juice has a lower potassium content, which is crucial for renal failure patients who need to limit potassium intake. Prune, grape, and apricot juices are high in potassium, which can be harmful in renal failure.

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