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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.

Sudden muscular contractions

Orthostatic hypotension

Anticholinergic effects

Tremors

Sedation

Increased urination

Answer and Explanation

Correct Answer : A,B,C,D,E

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.

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Correct Answer is B

Explanation

Rationale:

A. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing.

B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity.

C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression.

D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.

A. "Begin each feeding using the same breast." B. "Supplement breastfeedings with water every 12 hours." C. "Offer your infant the breast when he shows signs of hunger." D. "Limit the time your infant feeds to 10 minutes on each breast

Correct Answer is C

Explanation

Rationale:

A. "Begin each feeding using the same breast.": It's recommended to alternate breasts between feedings to ensure both breasts are emptied regularly. This helps maintain milk production and prevents engorgement or blocked ducts.

B. "Supplement breastfeedings with water every 12 hours.": Newborns do not require supplemental water. Breast milk provides all the necessary hydration and nutrients for the infant’s needs, even in hot weather.

C. "Offer your infant the breast when he shows signs of hunger.": Feeding on demand based on hunger cues—such as rooting, sucking motions, or hand-to-mouth activity—supports adequate nutrition, growth, and milk supply.

D. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding should not be time-restricted. Infants should be allowed to feed until they are satisfied, as some may take longer to extract enough milk, especially in the early weeks.

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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.

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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.