a nurse is assessing a client who has been taking haloperidol for several years which of the following assessment findings should the nurse recognize
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. A nurse is assessing 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: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.

2. A client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the hip?

Correct answer: B

Rationale: Placing a pillow between the client's legs when turning is essential to prevent hip dislocation post hip replacement surgery. This action helps maintain proper alignment of the hip joint and prevents adduction, which can lead to dislocation. Positioning the client's legs in adduction (choice A) can increase the risk of hip dislocation. Keeping the client in a low Fowler's position (choice C) or turning the client onto the affected side (choice D) does not directly address hip dislocation prevention.

3. A client is receiving discharge teaching for a new prescription of metformin. Which of the following client statements demonstrates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because clients taking metformin should avoid alcohol as it increases the risk of lactic acidosis. Choices A, B, and D are incorrect. Choice A is not specific to metformin but rather a general recommendation for some medications. Choice B is a good practice for medication adherence but does not relate specifically to metformin. Choice D is inaccurate as weight gain is not an expected side effect of metformin.

4. A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.

5. A nurse is reviewing the laboratory results of a client who has Cushing's disease. The nurse should expect an increase in which of the following laboratory values?

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, there is increased cortisol production, leading to elevated blood glucose levels. This occurs due to the role of cortisol in promoting gluconeogenesis and insulin resistance. Choices B, C, and D are incorrect because Cushing's disease is not typically associated with alterations in serum potassium, calcium, or sodium levels.

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