A patient is prescribed an antipsychotic medication for the management of schizophrenia. Which adverse effect should the nurse monitor closely in the patient?

Correct Answer: C

Rationale: Antipsychotic medications, especially first-generation antipsychotics, can cause extrapyramidal symptoms (EPS) as an adverse effect. EPS include symptoms such as muscle rigidity, tremors, akathisia (restlessness), and tardive dyskinesia (involuntary movements of the face and body). These symptoms are due to the medications' effects on the dopamine system in the brain. It is crucial for the nurse to monitor the patient closely for EPS because they can be uncomfortable, distressing, and may impact the patient's quality of life and medication adherence. Early recognition and management of EPS are essential to prevent further complications and improve the patient's overall well-being.

Correct Answer: C

Rationale: The practice of advocacy in nursing involves assessing the client's point of view and preparing to articulate this viewpoint. Advocacy requires that nurses actively listen to their patients, understand their perspectives, and ensure that their needs and wishes are communicated effectively within the healthcare team. By advocating for the client's point of view, nurses can help empower their patients to make informed decisions about their care and ensure that their best interests are always prioritized.

Correct Answer: D

Rationale: Confirming the patient's informed consent before the procedure is the most crucial action for the nurse to prioritize to ensure procedural safety during a thoracentesis. Informed consent is a legal and ethical requirement that ensures the patient understands the purpose of the procedure, its potential risks, benefits, and alternatives. By confirming informed consent, the nurse ensures that the patient has the necessary information and has willingly agreed to undergo the procedure. This process promotes patient autonomy, prevents misunderstandings, and reduces the likelihood of legal issues related to the procedure. Additionally, verifying informed consent helps establish a foundation of trust between the healthcare team and the patient. While other actions like positioning the patient correctly and ensuring pre-procedure antibiotics may also contribute to the safety of the procedure, obtaining informed consent is the foundational step that must be prioritized.

Correct Answer: C

Rationale: When providing health education to a patient, using clear and simple language is an essential aspect of effective communication. Medical terminology can be confusing and overwhelming for individuals without a medical background. By using language that the patient can easily understand, you improve their comprehension of the information being conveyed. Speaking quickly or using complex terms can actually hinder communication and may lead to misunderstanding. Clear and simple language helps ensure that the patient fully grasps the information and can make informed decisions about their health.

Correct Answer: D

Rationale: Non-maleficence is the ethical principle that emphasizes the obligation to avoid causing harm to patients. In this scenario, the ER nurse clarifies the doctor's prescription to ensure the correct dosage of the pain medication based on the pain scale assessment and the patient's age. By doing so, the nurse is ensuring that the medication is safe and effective for the patient, thus adhering to the principle of non-maleficence. This action demonstrates the nurse's commitment to preventing harm and promoting the well-being of the patient through proper medication management.

Correct Answer: C

Rationale: The clinical presentation of fever, malaise, maculopapular rash starting on the face and spreading to the trunk and extremities, along with leukopenia and thrombocytopenia, is highly suggestive of Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii. RMSF is a tick-borne illness transmitted by the American dog tick, Rocky Mountain wood tick, and brown dog tick. The constellation of symptoms described aligns well with the typical presentation of RMSF. Borrelia burgdorferi causes Lyme disease, which presents with erythema migrans but does not typically cause leukopenia or thrombocytopenia. Plasmodium falciparum is the causative agent of severe malaria and would present with symptoms such as cyclic fevers, anemia, and jaundice but not the described rash distribution.

Correct Answer: B

Rationale: Battery in the context of healthcare refers to the intentional and unauthorized touching of a patient. By applying a body restraint without a doctor's order, Nurse Edna has potentially committed battery against the patient. It is important for healthcare providers to obtain proper authorization before implementing any physical restraints on a patient to avoid legal liabilities such as battery.

Correct Answer: C

Rationale: The nurse should always keep Tensilon (Edrophonium) at the bedside of a client with myasthenia gravis. Tensilon is a fast-acting cholinesterase inhibitor that can be used for the diagnosis and emergency treatment of myasthenia crisis. It helps improve muscle strength temporarily by increasing the levels of acetylcholine at the neuromuscular junction. Administering Tensilon can help differentiate between a myasthenic crisis (marked improvement in muscle strength) and a cholinergic crisis (no improvement or worsening of muscle weakness). Keeping Tensilon at the bedside allows for prompt administration in case of a myasthenic crisis.

Correct Answer: A

Rationale: Maternal dehydration can contribute to a prolonged latent phase during labor. Dehydration can lead to reduced blood volume and electrolyte imbalances, which can result in ineffective uterine contractions. Without adequate hydration, the uterus may not contract effectively, causing irregular and infrequent contractions. It is important for the nurse to assess the woman's hydration status and encourage her to stay hydrated during labor to help regulate contractions and progress labor.