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 D
Explanation
Choice A rationale:
The provider does not choose a client's healthcare surrogate. Advance directives, including the appointment of a healthcare surrogate, allow individuals to make their own decisions about their medical treatment if they become unable to communicate their wishes. Clients have the right to designate their healthcare surrogate based on their preferences and values. This statement is incorrect as it misrepresents the purpose of advance directives.
Choice B rationale:
A healthcare surrogate does not need to be a family member. The choice of a healthcare surrogate is a personal decision made by the individual. It can be a family member, friend, or any other person whom the individual trusts to make medical decisions on their behalf. There is no requirement that the surrogate must be a family member.
Choice C rationale:
The provider cannot go against the client's wishes regarding advance directives. Advance directives are legally binding documents that outline the individual's preferences for medical treatment, including decisions to withhold or withdraw life-sustaining interventions. Healthcare providers are ethically and legally obligated to respect and follow the directives outlined by the client. Going against the client's wishes would be a violation of their autonomy and legal rights.
Choice D rationale:
The client can resume control of healthcare decisions after a temporary loss of competency if specified in the advance directives. Advance directives often include provisions stating that the individual's decision-making capacity should be
Correct Answer is A
Explanation
A is correct because ginger tea is an herbal remedy that has been shown to reduce nausea and vomiting in pregnancy.
B is incorrect because ginger tea does not have any effect on breast tenderness, which is a common symptom of pregnancy caused by hormonal changes.
C is incorrect because ginger tea does not have any effect on headaches, which can be caused by various factors such as dehydration, stress, or caffeine withdrawal in pregnancy.
D is incorrect because ginger tea does not have any effect on urinary frequency, which is a common symptom of pregnancy caused by increased blood volume and pressure on the bladder.
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