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 C
Explanation
A. Documenting suspicions in the client's medical record: While accurate documentation of objective findings is important, simply recording suspicions without following mandated reporting procedures does not fulfill the nurse’s legal responsibility. Documentation supports care but is not the primary legal action.
B. Notifying the caregiver of the findings: Informing the caregiver may be inappropriate and could place the client at further risk, especially if the caregiver is the suspected abuser. Legal obligations prioritize protecting the client over notifying the caregiver.
C. Reporting findings to social services: Nurses are mandated reporters of suspected elder abuse or neglect. Reporting objective findings of malnutrition and unexplained bruising to social services ensures that the client’s safety is addressed and fulfills the nurse’s legal responsibility.
D. Including findings during hand-off report: Communicating relevant findings during hand-off is part of good nursing practice, but it does not meet the legal requirement to report suspected abuse to appropriate authorities.
Correct Answer is C
Explanation
A. Blood pressure 108/68 mm Hg: This blood pressure is slightly lower than average but generally within a safe range. Hydromorphone can cause hypotension, but this reading alone does not necessitate immediate intervention.
B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is within the normal adult range (12–20/min), indicating that the client is not experiencing significant opioid-induced respiratory depression.
C. Urinary output 160 mL/8 hr: A urinary output of 160 mL over 8 hours is significantly below normal (expected >30 mL/hr). Oliguria can indicate opioid-induced urinary retention or other complications. The nurse should notify the provider for assessment and possible intervention.
D. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most adults and does not indicate hypoxemia. Continued monitoring is appropriate, but immediate notification is not required.
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