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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Murmurs can be a normal finding in older adults due to age-related changes in the heart valves or blood flow. They are not necessarily indicative of pathology if they are not associated with symptoms or changes in the client's condition.

B. Absent heart sounds would be abnormal and could indicate severe underlying issues such as cardiac arrest or severe hypovolemia.

C. While no adventitious sounds are generally expected, the presence of murmurs is considered normal in this age group.

D. Adventitious sounds (such as crackles or wheezes) are not normal in heart auscultation and would suggest potential pathologies.

A. Check femoral site for hematoma formation. B. Evaluate the integrity of the IV insertion site. C. Stimulate the client to take deep breaths. D. Assess distal lower extremity capillary refill.

Correct Answer is A

Explanation

A. Checking the femoral site for hematoma formation is crucial because pain at the groin insertion site could indicate bleeding or hematoma formation, which is a potential complication of cardiac catheterization.

B. Evaluating the IV insertion site is important but not as directly related to the groin pain as checking the femoral site.

C. Stimulating the client to take deep breaths is helpful for respiratory function but does not address the groin pain issue.

D. Assessing distal lower extremity capillary refill is important for overall circulation but is not the immediate priority in this scenario.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

The nurse is caring for a client with the sexually transmitted infection (STI) trichomoniasis who reports having had unprotected sex. Which response should the nurse provide?

An client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day intravenously in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)