A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

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PN ATI Capstone Proctored Comprehensive Assessment B Quizlet Questions

Question 1 of 9

A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

Correct Answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

Question 2 of 9

A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?

Correct Answer: B

Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.

Question 3 of 9

A client has developed a pulmonary embolism. Which of the following interventions should the nurse implement first?

Correct Answer: A

Rationale: Administering oxygen is the priority intervention for a client with a pulmonary embolism. Pulmonary embolism can lead to impaired gas exchange, causing hypoxemia. Administering oxygen helps to maintain adequate oxygenation levels. Thoracentesis is not indicated for a pulmonary embolism, as it is a procedure to remove fluid or air from the pleural space, not a treatment for embolism. Elevating the client's lower extremities is not a priority in the management of a pulmonary embolism. Administering anticoagulant therapy is important in the treatment of pulmonary embolism to prevent further clot formation, but it is not the first intervention. Oxygen administration takes precedence to address the immediate oxygenation needs of the client.

Question 4 of 9

A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

Correct Answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

Question 5 of 9

A client with lactose intolerance, who has eliminated dairy products from the diet, should increase consumption of which of the following foods?

Correct Answer: A

Rationale: Spinach is the correct answer because it is a good source of calcium, which is important for clients with lactose intolerance who are not consuming dairy products. Peanut butter, ground beef, and carrots do not provide as much calcium as spinach and are not the best choices for meeting the calcium needs of clients with lactose intolerance.

Question 6 of 9

A client with heart failure is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?

Correct Answer: D

Rationale: The correct answer is D. Swelling in the feet can indicate worsening heart failure due to fluid retention, and clients should report this to their healthcare provider immediately. Choices A, B, and C are incorrect because weighing once a week may not provide timely information on fluid retention, timing of diuretic medication is usually advised in the morning to prevent nocturia, and limiting fluid intake to 3 liters per day may not be appropriate for all clients with heart failure.

Question 7 of 9

A nurse is preparing to administer medications to a client who is NPO and has an NG tube for suction. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct action for the nurse to take when administering medications to a client with an NG tube for suction who is NPO is to clamp the NG tube for 30 minutes after medication administration. This is done to allow for proper absorption of the medications before resuming suction. Choice A is incorrect because medications should not be mixed with enteral feedings as it may affect the drug's effectiveness. Choice C is incorrect as medications should not be inserted directly into the NG tube without dilution, as this can cause clogging or affect the tube. Choice D is incorrect because connecting the NG tube to continuous suction after medication administration can interfere with the absorption of the medications.

Question 8 of 9

A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?

Correct Answer: A

Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.

Question 9 of 9

A provider has written a do not resuscitate (DNR) order for a client who is comatose and does not have advance directives. A member of the client's family says, 'I wonder when the doctor will tell us what's going on.' Which of the following actions should the nurse take first?

Correct Answer: D

Rationale: The correct action for the nurse to take first is to ask the family what the provider has discussed with them. This allows the nurse to clarify any misunderstandings and ensures that the family is fully informed before providing further information. Option A is not the best choice because it assumes the need for more information without first understanding what has already been communicated. Option B is premature as the family may not be ready for grief counseling at this stage. Option C, although a good general practice, is not the most appropriate immediate action in this situation where clarifying existing information is crucial.

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