Nursing Elites

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?

• A. Lip-smacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

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 charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following is a benefit of this treatment?

• A. Systemic analgesic effect
• B. Increase in metabolism
• C. Decreased capillary permeability
• D. Vasodilation

Correct answer: C

Rationale: The correct answer is C: Decreased capillary permeability. Ice application helps decrease capillary permeability, which in turn reduces swelling and inflammation at the injury site. This vasoconstriction effect helps to limit the extent of the injury. Choices A, B, and D are incorrect. Applying ice locally does not produce a systemic analgesic effect but rather a localized numbing effect. It does not increase metabolism but rather slows down metabolic processes in the affected area. Additionally, ice application causes vasoconstriction, not vasodilation.

3. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?

• A. Level of consciousness
• B. Deep tendon reflexes
• C. Blood pressure
• D. Urinary output

Correct answer: C

Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.

4. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?

• A. Blood pressure 140/90 mm Hg
• B. Urine output of 40 mL/hr
• C. Temperature 38.2°C (100.8°F)
• D. Hemoglobin 8 g/dL

Correct answer: C

Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.

5. A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

• A. A client who has a urine specific gravity of 1.010.
• B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr.
• C. A client who has a hematocrit of 45%.
• D. A client who has a temperature of 39°C (102°F).

Correct answer: D

Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.

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