a nurse is teaching a client about the use of risperidone which of the following should be included
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. When teaching a client about the use of risperidone, which of the following should be included?

Correct answer: B

Rationale: The correct answer is B: 'Monitor for metabolic syndrome.' Risperidone is not an SSRI but an atypical antipsychotic. Choice A is incorrect. Choice C is also incorrect as risperidone, like any medication, can have side effects. Choice D is wrong because alcohol consumption should generally be avoided while taking risperidone. Educating clients about monitoring for metabolic syndrome, weight gain, and other potential side effects is crucial in managing their health effectively while on this medication.

2. A client with Ménière’s disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: The correct intervention for a client with Ménière’s disease experiencing vertigo is to provide a low sodium diet. Limiting sodium helps to reduce fluid retention, which in turn decreases the manifestations of Ménière’s disease. Encouraging bed rest (Choice A) may be necessary during acute episodes but is not a long-term solution. Restricting fluid intake (Choice B) to the morning hours does not specifically address the underlying issue of fluid retention associated with Ménière’s disease. Administering aspirin (Choice C) is not recommended for Ménière’s disease as it can worsen symptoms.

3. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a catheter occlusion?

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention indicates that the bladder is full and there is impaired elimination, which could be caused by catheter occlusion. Pain during urination (choice A) is not typically associated with catheter occlusion but may indicate a urinary tract infection. Cloudy urine (choice C) can be a sign of infection but is not specific to catheter occlusion. Blood in the catheter tube (choice D) may indicate trauma during catheter insertion but is not a typical finding in catheter occlusion.

4. A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client's membranes have ruptured?

Correct answer: C

Rationale: The correct answer is the Fern test. The Fern test is specifically used to confirm the rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid. The Nonstress test (Choice A) is used to monitor fetal heart rate and movement, not to confirm ruptured membranes. The Biophysical profile (Choice B) is a prenatal ultrasound evaluation to assess fetal well-being, not to confirm ruptured membranes. Amniocentesis (Choice D) involves the aspiration of amniotic fluid for various diagnostic purposes, not specifically to confirm ruptured membranes.

5. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?

Correct answer: B

Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.

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