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Question 1 of 5

For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:

Correct Answer: A

Rationale: Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. Most antipsychotic drugs are chemically similar and will produce the same side effects.

Question 2 of 5

A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

Correct Answer: D

Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.

Question 3 of 5

Which of the following are sources of dietary iron?

Question Image

Correct Answer: B, D, F

Rationale: Iron-rich foods include molasses (
B), raisins (
D), and collards (F). Cheese (
A), carrots (
C), and peanut butter (E) are low in bioavailable iron.

Question 4 of 5

A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:

Correct Answer: A

Rationale: Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto-Bismol is also classified as a salicylate and should be avoided. Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. Although viral pneumonia can be a complication of influenza, this would not be an initial priority.

Question 5 of 5

A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:

Correct Answer: B

Rationale: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.

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