Nursing Elites

1. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

• A. Dizziness when standing.
• B. Shuffling gait and hand tremors.
• C. Urinary retention.
• D. Fever of 102°F.

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

2. A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?

• A. Administer a PRN dose of lorazepam (Ativan).
• B. Encourage the client to perform facial exercises.
• C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
• D. Document the findings and continue to monitor the client.

Correct answer: C

Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.

3. A client with schizophrenia is prescribed olanzapine (Zyprexa). What is the most important side effect for the nurse to monitor?

• A. Hypotension
• B. Weight gain
• C. Dry mouth
• D. Tachycardia

Correct answer: B

Rationale: The correct answer is B: Weight gain. Olanzapine (Zyprexa) is known to cause significant weight gain in patients. This side effect is crucial to monitor because it can lead to metabolic syndrome, diabetes, and cardiovascular issues. Monitoring the client's weight regularly and providing appropriate dietary guidance is essential. Hypotension (choice A), dry mouth (choice C), and tachycardia (choice D) are not commonly associated with olanzapine use and are not the primary side effects to monitor in this case.

4. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?

• A. 'I'll leave your tray here. I am available if you need anything else.'
• B. 'You're not being poisoned. Why do you think someone is trying to poison you?'
• C. 'No one on this unit has ever died from poisoning. You're safe here.'
• D. 'I will talk to your healthcare provider about the possibility of changing your diet.'

Correct answer: A

Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.

5. A client who has been diagnosed with borderline personality disorder is exhibiting manipulative behavior. What is the most important intervention for the LPN/LVN to implement?

• A. Set clear, consistent limits on manipulative behavior.
• B. Ignore the manipulative behavior to avoid reinforcing it.
• C. Remind the client that manipulative behavior is unacceptable.
• D. Explain the consequences of manipulative behavior to the client.

Correct answer: A

Rationale: Setting clear, consistent limits on manipulative behavior is the most important intervention for a client diagnosed with borderline personality disorder. This approach helps establish boundaries, maintain a therapeutic environment, and provide structure for the client. Choice B is incorrect because ignoring manipulative behavior can lead to its reinforcement. Choice C, while important, may not be as effective as directly setting limits. Choice D focuses on consequences rather than immediate intervention, making it less effective than setting clear limits.

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