The nurse is continuing to assist in the care of the client.
Complete the following sentence by using the lists of options.
The nurse should reinforce teaching with the client to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Rationale for correct choices:
• Monitor body temperature: Paliperidone, an antipsychotic, can increase the risk of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening condition characterized by hyperthermia, muscle rigidity, and altered mental status. Teaching the client to monitor body temperature helps with early recognition of NMS and timely intervention.
• Report sore throat: Paliperidone can cause hematologic adverse effects, including leukopenia, neutropenia, and agranulocytosis. A sore throat may be an early sign of infection due to low white blood cell counts. Reinforcing the need to report symptoms like sore throat ensures prompt evaluation and prevents serious complications.
Rationale for incorrect choices:
• Anticipated increased bruising: Although some antipsychotics may rarely affect platelet function, paliperidone is not commonly associated with increased bruising. This is not a primary teaching point for the client. Monitoring for bruising is less critical than monitoring for signs of infection or NMS.
• Stop taking contraceptive medication: There is no evidence that paliperidone interacts with contraceptives in a way that requires discontinuation. Advising the client to stop contraceptive medication is unnecessary and could place the client at risk for unintended pregnancy.
• Expect weight loss: Paliperidone is more commonly associated with weight gain rather than weight loss. Counseling the client about expecting weight loss would be inaccurate and could mislead them regarding lifestyle and dietary management.
• Follow a low-sodium diet: Paliperidone does not require sodium restriction. Low-sodium diet recommendations are not indicated unless the client has a comorbid condition like hypertension or heart failure. This is unrelated to the medication’s primary safety concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for correct choices:
• Placental abruption: The client exhibits sudden-onset hypertension, epigastric pain, headache, and facial edema at 30 weeks gestation, which are risk factors for placental abruption. Abruption involves premature separation of the placenta from the uterine wall, leading to maternal and fetal compromise. Early recognition is critical due to potential hemorrhage, fetal distress, and preterm delivery.
• Hypertension: The client’s blood pressure readings (148/94 mm Hg and 156/96 mm Hg) are significantly elevated for gestation, indicating preeclampsia or gestational hypertension. Hypertension increases the risk for placental abruption by causing vascular injury and reduced placental perfusion.
Rationale for incorrect choices:
• Postpartum hemorrhage: Postpartum hemorrhage occurs after delivery and is not a risk during the antepartum period at 30 weeks. While abruption can lead to bleeding, postpartum hemorrhage specifically refers to hemorrhage after birth and is not directly indicated by current findings.
• Placenta previa: Placenta previa involves implantation of the placenta over or near the cervical os, often presenting with painless vaginal bleeding. The client reports epigastric pain, headache, and hypertension, which are not characteristic of placenta previa.
• Hyperreflexia: While hyperreflexia is noted (DTRs 3+ bilaterally) and may indicate preeclampsia, it is a clinical finding rather than a direct cause of placental abruption. It is an important assessment parameter but does not independently increase the risk of abruption.
• Vomiting: Vomiting is a symptom the client reports but is not a primary risk factor for placental abruption. It may indicate associated preeclampsia or general discomfort but does not contribute directly to vascular placental separation.
Correct Answer is ["A","D","E"]
Explanation
A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.
B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.
C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.
D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.
E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.
F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.
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