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
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

1. 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.

2. A nurse is reviewing the laboratory results of a newborn who is 24 hours old. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C: Bilirubin 4 mg/dL. A bilirubin level of 4 mg/dL is elevated for a newborn and requires monitoring and potential intervention to prevent complications such as jaundice and kernicterus. Elevated bilirubin levels in newborns can lead to serious neurological consequences. Choices A, B, and D are within normal ranges for a newborn and do not require immediate reporting to the provider. Therefore, the nurse should prioritize reporting the elevated bilirubin level to the provider for further evaluation and management.

3. A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?

Correct answer: A

Rationale: The correct answer is A. The MMR vaccine is contraindicated in pregnant women due to the risk of fetal harm. It is recommended that women avoid becoming pregnant for at least 4 weeks after receiving the vaccine. Choice B, client allergy to strawberry, is not a contraindication for the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication for the MMR vaccine.

4. A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform?

Correct answer: A

Rationale: Corrected Rationale: The client with a cystocele should perform Kegel exercises to strengthen the pelvic floor muscles, reducing the risk of pelvic organ prolapse and stress urinary incontinence. Kegel exercises specifically target the muscles that support the pelvic organs. Isometric exercises focus on static muscle contractions and may not be as effective as Kegel exercises for strengthening the pelvic floor. Circumduction exercises involve circular movements at joints and are not specific to pelvic floor muscle strengthening. Uterine extension exercises do not directly target the pelvic floor muscles and are not indicated for cystocele management.

5. A client with heart failure who presents with dyspnea, bibasilar crackles, and frothy sputum should receive which dietary recommendation?

Correct answer: B

Rationale: The correct answer is to reduce sodium intake. In heart failure, excess sodium can lead to fluid retention, exacerbating symptoms like dyspnea, bibasilar crackles, and frothy sputum. Therefore, reducing sodium intake is crucial in managing heart failure. Decreasing protein intake is not typically recommended in heart failure management. Increasing fluid intake would worsen the condition by further contributing to fluid overload. Decreasing calcium intake is not directly related to managing heart failure symptoms such as dyspnea, bibasilar crackles, and frothy sputum.

Similar Questions

A nurse is teaching a client about the use of aspirin. Which of the following should be included?
A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?
A nurse is reviewing psychosocial stages of development for a school-age child. What would be an expected behavioral finding for this child?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses