The nurse continues to care for the client.

Exhibits

The nurse is planning care for the client. For each client problem below, click to specify the nursing Intervention the nurse should include in the client's plan of care. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.

Finding

Nursing Intervention

Client's restlessness

dropdown

Client's behavior towards staff

dropdown

Client's hygiene

dropdown

Note: Each drop down must have 1 response selected

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"C"}

Rationale for Correct Choices:

Decrease environmental stimulation: Reducing stimulation helps manage restlessness by preventing sensory overload, which can exacerbate agitation in clients with schizophrenia. A calm environment supports focus and reduces the risk of escalation or aggressive behavior.
Provide constructive diversions: Constructive diversions such as quiet activities or art can channel aggressive energy into safe outlets. For a client expressing paranoia and aggression toward staff, structured and non-threatening engagement is therapeutic and promotes emotional regulation.
Use visual cues to promote attention to tasks: Clients with schizophrenia often struggle with distractibility and disorganized thought processes. Visual prompts and step-by-step guides help them focus and complete hygiene tasks that would otherwise be overwhelming or forgotten.

Rationale for Incorrect Choices:

Avoid discussing the client’s negative emotions: Suppressing emotional expression is countertherapeutic. Clients benefit from validating their emotions through supportive communication, which also builds trust and rapport necessary for effective care.
Discourage participation in physical exercise: Exercise can be beneficial in reducing anxiety and agitation. Discouraging movement may increase restlessness or internal distress in clients who need outlets for excess energy.
Minimize engagement with the client: Withdrawal from the client may reinforce feelings of paranoia or abandonment. Consistent therapeutic engagement is essential for building trust and managing disruptive behaviors.
Place the client in a room away from the nurses’ station: Isolating a paranoid and aggressive client may increase their risk of harming themselves or others. Close observation near the nurses’ station ensures safety and quick intervention if escalation occurs.
Instruct client to perform tasks independently: Clients with cognitive disruptions may not be able to initiate or complete hygiene without cues. Expecting full independence without support can lead to frustration, noncompliance, or neglect of self-care.
Enact consequences for uncompleted hygiene tasks: Punitive measures are inappropriate for clients with psychiatric disorders who are impaired in their ability to carry out daily routines. Behavioral reinforcement must be therapeutic and supportive, not disciplinary.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Rationale:

A. Sudden muscular contractions: Antipsychotics like haloperidol and chlorpromazine can cause extrapyramidal symptoms (EPS), including acute dystonia, which manifests as sudden, involuntary muscle contractions typically affecting the face, neck, or back.

B. Orthostatic hypotension: Chlorpromazine, a low-potency typical antipsychotic, often causes orthostatic hypotension due to its alpha-adrenergic blockade, increasing fall risk, especially in older adults or those new to therapy.

C. Anticholinergic effects: These include dry mouth, blurred vision, constipation, and urinary retention. Chlorpromazine is particularly known for its anticholinergic side effects due to its action on muscarinic receptors.

D. Tremors: Tremors are part of parkinsonian side effects, another form of EPS commonly caused by haloperidol. They result from dopamine blockade in the nigrostriatal pathway.

E. Sedation: Both haloperidol and chlorpromazine can cause sedation. Chlorpromazine is especially sedating due to its histamine (H1) receptor blockade, which depresses the CNS.

F. Increased urination: Not typically associated with these medications. In fact, anticholinergic effects from chlorpromazine more often lead to urinary retention, not increased urination.

A. Instruct the client to have his testosterone checked in 1 week B. Wear clean gloves to apply the gel. C. Apply the gel to the client's genital region D. Advise the client to wait 1 hr before showering or swiming

Correct Answer is D

Explanation

Rationale:

A. Instruct the client to have his testosterone checked in 1 week: Testosterone levels are typically monitored after several weeks of therapy, not within just one week. Early testing may not accurately reflect the medication's effectiveness or stability in the bloodstream.

B. Wear clean gloves to apply the gel: Gloves must be worn, but they should be disposable and protective not simply clean gloves. This prevents accidental transdermal absorption of testosterone by the nurse, which can have hormonal effects, especially in females.

C. Apply the gel to the client's genital region: Testosterone gel should not be applied to the genital area due to the risk of irritation and unpredictable absorption. Recommended sites include the shoulders, upper arms, or abdomen where the skin is intact and dry.

D. Advise the client to wait 1 hr before showering or swimming: The client should be instructed to wait at least 1 hour to allow for full absorption of the gel. Showering or swimming too soon can reduce the effectiveness of the medication.

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Finding	Nursing Intervention
Client's restlessness	dropdown
Client's behavior towards staff	dropdown
Client's hygiene	dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client.Exhibits The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is preparing to administer testosterone gel to a client who has hypogonadism. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the nurse preceptor?

A nurse is caring for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to administer?

A nurse is caring for a client who has been on hemodialysis for the past 5 years. The client is refusing hemodialysis and says, "I'm tired of wasting my life; I would rather die." Which of the following statements should the nurse make?

A nurse is witnessing a surgeon obtain informed consent from a client. Which of the following legal requirements is met by this action?

A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

The nurse is continuing to care for the client. Exhibits The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should first dropdown and then dropdown.