Patient Data

Exhibits

Data is evaluated to determine possible condition and appropriate interventions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress

Answer and Explanation

The Correct Answer is []

Rationale for Correct Choices:

• Extrapyramidal reaction: The client exhibits muscle stiffness, constant leg shaking, forward-backward rocking, and abnormal head positioning, all of which are hallmark signs of extrapyramidal symptoms (EPS) often caused by antipsychotic medications like haloperidol and chlorpromazine. Recognizing EPS early prevents further complications such as severe dystonia or Parkinsonism.

• Initiate one-on-one observation: Continuous observation is essential to ensure client safety, particularly due to agitation, abnormal movements, and risk of injury from dystonia or uncontrolled motor activity, which can be exacerbated in psychiatric patients on antipsychotics.

• Education on administration and side effects of haloperidol: Teaching the client and caregivers about haloperidol’s potential side effects, including EPS, akathisia, and tardive dyskinesia, enhances adherence, promotes early reporting of adverse effects, and supports safe medication management.

• Gait and muscle strength: Monitoring gait and muscle strength allows the nurse to track the severity and progression of extrapyramidal symptoms, assess mobility limitations, and evaluate the effectiveness of interventions like anticholinergic medications or dosage adjustments.

• Improvement in symptoms: Observing improvement in EPS or agitation provides measurable evidence that interventions are effective, guiding ongoing care and any necessary modifications to therapy or dosing.

Rationale for Incorrect Choices:

• Mucositis: Mucositis involves inflammation and ulceration of the mucous membranes, typically related to chemotherapy or radiation therapy, and is not consistent with this client’s current presentation of abnormal motor activity and psychiatric symptoms.

•Hypertensive crisis: The client’s blood pressure is within a normal to mildly elevated range, and there are no signs of acute end-organ damage, so hypertensive crisis is unlikely in this scenario.

• Parkinson’s Disease: Parkinsonism is a chronic neurodegenerative disorder characterized by resting tremor, bradykinesia, and rigidity, not acute onset EPS triggered by antipsychotic use in a young adult with schizophrenia.

• Institute oral hygiene to prevent candidiasis: Oral hygiene is generally important but does not address the acute neurological side effects of antipsychotic medications, making it nonessential for EPS management.

• Immediate dietician consult: While nutrition is important, it is not immediately relevant for extrapyramidal symptoms and does not address the urgent motor complications caused by antipsychotics.

• Administer antihypertensive: The client’s blood pressure is not critically elevated, and there are no indications of hypertensive emergency, so antihypertensive therapy is unnecessary.

• Blood pressure: Monitoring blood pressure is routine but not directly related to tracking extrapyramidal symptoms or response to antipsychotic therapy in this case.

• Swallowing: While dysphagia can occur in severe EPS, this client does not currently present with swallowing difficulties, making it less critical to monitor compared to gait and muscle strength.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Drinking grapefruit juice will reduce the effects of the medication: Grapefruit juice can interact with itraconazole, but it typically increases rather than reduces drug levels. The client’s awareness of potential interactions is important, though clarification may be needed.

B. If I experience any difficulty with breathing I will report it: Respiratory symptoms could indicate an allergic reaction or adverse effect; reporting these promptly is appropriate and demonstrates understanding.

C. Monitoring for changes in stool color is important: Itraconazole can affect liver function, and changes in stool or urine may signal hepatotoxicity. Monitoring these changes is appropriate teaching.

D. I should take the medication with antacids: Antacids reduce gastric acidity, which decreases itraconazole absorption and effectiveness. The client should be instructed to avoid antacids around the time of medication administration.

A. Instruct incentive spirometry use every hour. B. Use petroleum based lotion on skin. C. Administer antibiotics. D. Suggest that client ambulate often. E. Encourage consumption of protein and vitamin C. F. Apply thromboembolism deterrent stockings (TED).

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Patient Data Exhibits The nurse is anticipating which additional medications the healthcare provider may prescribe for the client to manage side effects while on morphine sulfate. Select the 3 medications that would be most appropriate to manage the side effects of morphine sulfate.

Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Which oral medication can the nurse safely cut in half?