A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?
"I haven't had a drink of alcohol since I started taking these injections."
"I spend several hours a day outside gardening when it's sunny."
"I check my blood pressure once a week.
"I chew sugar-free gum several times daily."
The Correct Answer is B
A. This statement indicates that the client has abstained from alcohol while on haloperidol decanoate. This is a positive statement and shows compliance with recommendations, as alcohol can interact with medications and affect their effectiveness or cause adverse reactions. There is no immediate concern with this statement.
B. Haloperidol can increase sensitivity to sunlight (photosensitivity). Spending several hours outside gardening in the sun could potentially increase the risk of sunburn or other skin reactions due to photosensitivity. The nurse should address this statement by educating the client about the need to use sunscreen, wear protective clothing, and avoid prolonged sun exposure, especially during peak sunlight hours.
C. Regular monitoring of blood pressure is generally recommended for clients taking haloperidol, as it can occasionally cause hypotension (low blood pressure) as a side effect. Checking blood pressure once a week is a reasonable frequency, but the nurse should ensure that the client understands the signs and symptoms of hypotension and knows when to seek medical attention if blood pressure readings are abnormal.
D. Chewing sugar-free gum is generally not contraindicated while taking haloperidol. However, if the gum contains caffeine or other stimulants, it could potentially exacerbate certain side effects of the medication, such as tremors or restlessness. The nurse should inquire further about the type of gum being used and educate the client about potential interactions or side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This response dismisses the client's experience and hallucination as a mistake. It invalidates the client's feelings and does not acknowledge the client's reality. It can increase the client's distress and undermine trust in the nurse's communication.
B. While this statement provides factual information about the need for the blood specimen, it does not address the client's hallucination or their fear related to it. It may come off as indifferent to the client's feelings and concerns.
C. This option dismisses the client’s feelings without addressing them appropriately.
D. This response validates the client's experience and expresses empathy for their feelings of fear. It acknowledges the hallucination without confirming its reality and shows understanding of how
frightening the experience might be for the client. This response is supportive and helps build trust between the nurse and the client.
Correct Answer is ["B","C","D","E"]
Explanation
A. Being married is generally considered a protective factor against suicide. Married individuals often have social support and a sense of belonging, which can reduce suicide risk. Therefore, this would not be identified as a risk factor for suicide.
B. Alcohol use disorder is a significant risk factor for suicide. Alcohol can impair judgment, increase impulsivity, and exacerbate underlying mental health issues. It is associated with higher rates of suicidal ideation and attempts.
C. Family history of suicide, including among siblings, is a known risk factor. Exposure to suicide within the family can contribute to feelings of hopelessness, increase perceived acceptability of suicide, and impact mental health negatively.
D. Access to firearms is a well-established risk factor for completed suicide. Firearms are highly lethal, and their presence increases the likelihood of a fatal suicide attempt compared to other means.
E. Terminal illness, including conditions like terminal liver cancer, can contribute to feelings of hopelessness and despair, potentially increasing suicide risk. The distress related to the prognosis and physical symptoms can exacerbate mental health issues.
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