A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?
Implement fall precautions for the client
Monitor the client's thyroid function
Place the client on a fluid restriction
Discontinue the medication if hallucinations occur
The Correct Answer is A
Implement fall precautions for the client.
- A. Implement fall precautions for the client. This is correct because risperidone can cause orthostatic hypotension, which can increase the risk of falls and injuries. The nurse should advise the client to change positions slowly, avoid alcohol and dehydration, and use assistive devices as needed.
- B. Monitor the client's thyroid function. This is incorrect because risperidone does not affect thyroid function. The nurse should monitor the client's thyroid function if they are taking lithium, which can cause hypothyroidism.
- C. Place the client on a fluid restriction. This is incorrect because risperidone does not cause fluid retention or overload. The nurse should encourage adequate fluid intake and monitor the client's fluid balance.
- D. Discontinue the medication if hallucinations occur. This is incorrect because hallucinations are a symptom of schizophrenia, not a side effect of risperidone. The nurse should not discontinue the medication abruptly, as this can cause withdrawal symptoms and relapse of psychosis. The nurse should assess the client's response to the medication, report any adverse effects, and adjust the dosage as prescribed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP. -
B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.
- C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.
- D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.
Correct Answer is A
Explanation
Choice A rationale:
Irritability is a common withdrawal symptom in newborns exposed to cocaine during pregnancy. Cocaine exposure can lead to irritability, restlessness, and difficulty in consoling the newborn.
Choice B rationale:
Hypotonicity, or decreased muscle tone, is not a common finding associated with cocaine exposure in newborns. Cocaine exposure more commonly results in hypertonicity, where the muscles are tense and rigid.
Choice C rationale:
Decreased auditory startle response is not a typical finding associated with cocaine exposure. Newborns exposed to cocaine may have an exaggerated startle response, which is the opposite of the expected finding in this case.
Choice D rationale:
Increased head circumference is not a characteristic finding associated with cocaine exposure. Cocaine exposure is more likely to cause growth restriction, low birth weight, and microcephaly (small head size) in newborns.
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