A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?

Blood pressure 170/82 mm Hg.

Respiratory rate 18/min.

Pulse rate 48/min.

Potassium 4 mEq/L.

Answer and Explanation

The Correct Answer is C

Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.

Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.

Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.

Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.

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Correct Answer is B

Explanation

“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.

Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.

Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.

Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.

Normal ranges for spleen size are 7 to 14 cm in length and 3 to 4 cm in thickness.

A. Warn the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination. B. Keep the facility’s security personnel constantly visible to the client throughout treatment. C. Collaborate with the client to develop a daily physical exercise routine. D. Agree that the hallucinations are real if the client exhibits aggressive behavior toward other clients.

Correct Answer is C

Explanation

Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.

Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.

Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.

Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.

The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.

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A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about self-care with an adolescent client who has infectious mononucleosis with splenomegaly. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior. Which of the following interventions should the nurse include in the initial plan?

Correct Answer is C

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