The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Shuffling gait and stooped posture.

Rocks back and forth in the chair.

Muscle spasms of the back and neck.

Lip smacking and frequent eye blinking.

Answer and Explanation

The Correct Answer is C

A. Shuffling gait and stooped posture are common side effects of antipsychotic medications and may require intervention but are not immediately dangerous.

B. Rocking back and forth in the chair can be a self-soothing behavior in individuals with schizophrenia and usually does not require immediate intervention.

C. Muscle spasms of the back and neck (dystonia) can be a sign of a serious side effect of antipsychotic medications known as extrapyramidal symptoms and require immediate intervention to prevent complications such as airway obstruction.

D. Lip smacking and frequent eye blinking can indicate tardive dyskinesia, a long-term side effect of antipsychotic medication, but it is not an immediate emergency.

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Correct Answer is A

Explanation

A. Infusing normal saline intravenously is crucial as the infant shows signs of dehydration (weak cry, no tears), and intravenous fluids are necessary to restore hydration and electrolyte balance.

B. Applying an external cooling blanket may be necessary to manage fever but does not address the dehydration issue.

C. Providing an electrolyte solution is helpful, but given the infant’s refusal to drink, IV fluids are more immediate and effective.

D. Administering an antipyretic rectally might help manage fever but does not address the dehydration or fluid needs.

A. Do not take diabetes medication when feeling sick. B. Obtain an A1C blood test every year to monitor glucose control. C. Follow the individualized meal plan and avoid high fat diets. D. Apply lotion to entire foot to prevent cracks in the skin.

Correct Answer is C

Explanation

A. It is important for clients to continue taking their diabetes medication even when they are feeling sick to prevent hyperglycemia and other complications.

B. An A1C blood test should be obtained more frequently than once a year, typically every 3 months, to effectively monitor glucose control.

C. Following an individualized meal plan and avoiding high-fat diets are key components of managing type 2 diabetes mellitus. This helps maintain blood glucose levels within the target range and reduces the risk of complications.

D. Applying lotion to the feet is important to prevent dry skin and cracks, but it should not be applied between the toes as this can increase moisture and risk of infection.

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The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about managing care at home. Which information verbalized by the client indicates understanding?

Correct Answer is C

Explanation

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