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.

Correct Answer: B

Rationale: The correct answer is B: Glycosylated hemoglobin (HbA1c). The glycosylated hemoglobin test measures average blood glucose levels over the past 2-3 months, providing an indication of long-term glycemic control in clients with diabetes. Choice A, postprandial blood glucose, reflects blood sugar levels after a meal and does not provide a long-term view. Choice C, glucose tolerance test, evaluates the body's ability to process sugar but does not offer a continuous assessment like the HbA1c test. Choice D, fasting blood glucose, measures blood sugar levels after a period of fasting, which is more indicative of immediate glycemic status rather than long-term management.

Correct Answer: D

Rationale: The correct answer is D because transporting a stable child to x-ray is a task that can be safely delegated to an assistive personnel. This task does not require clinical judgment or specialized skills. Choices A, B, and C involve assessments and interventions that require nursing judgment and should be performed by a qualified nurse. Initiating a dietary consult for a toddler involves assessing the child's nutritional needs and must be done by a nurse. Administering a glycerin suppository to a preschool-age child requires medication administration skills and knowledge of appropriate dosages, which are within the nurse's scope of practice. Evaluating gastric residual following intermittent feeding of an adolescent is a clinical assessment that requires interpretation and decision-making based on the findings, making it a nursing responsibility.

Correct Answer: D

Rationale: A pulse of 54/min indicates bradycardia, which is a side effect of propranolol, a beta-blocker. The medication should be withheld if the client's pulse drops below 60/min. The other findings (sodium levels, blood pressure, and potassium levels) are not directly indicative of the need to withhold propranolol.

Correct Answer: C

Rationale: In this scenario, the correct response by the nurse is option C, "Come outside with me for a walk." This option is appropriate because it offers the client a chance to de-escalate the situation in a non-confrontational manner. Taking the client outside for a walk provides a distraction, a change of scenery, and an opportunity for the client to calm down in a less stimulating environment. Option A, apologizing to others for the client's behavior, is not the best response as it does not address the client's behavior or help in de-escalating the situation. Option B, expressing disappointment, may further agitate the client and does not offer a constructive solution. Option D, threatening seclusion if the client doesn't calm down, is not a therapeutic or trauma-informed approach. It can escalate the situation and may lead to a power struggle or increased agitation. In an educational context, it is crucial for nurses working in mental health facilities to have training in de-escalation techniques and communication skills to effectively manage challenging behaviors. Approaches that prioritize the client's safety, dignity, and emotional well-being are essential in providing quality care in mental health settings.