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 B

Explanation

A. Auscultating below the umbilicus is not effective for assessing urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

C. Measuring the girth of the lower abdomen can be useful but is less specific than palpation for assessing bladder fullness.

D. Observing the urine's appearance does not directly assess for urinary retention.

A. Keep the infant home from daycare for the next two days. B. Apply a cool pack to the injection site to reduce discomfort. C. Any level of fever is serious and should be reported right away. D. Administer children's aspirin to help prevent inflammation.

Correct Answer is B

Explanation

A. It is not necessary to keep the infant home from daycare unless the infant has a fever or other signs of illness.

B. Applying a cool pack to the injection site can help reduce discomfort and swelling.

C. Mild fever after vaccinations is common and not typically serious, but high or persistent fever should be reported.

D. Aspirin should not be given to children due to the risk of Reye's syndrome. Acetaminophen or ibuprofen (for infants older than 6 months) are safer alternatives for reducing fever and discomfort.

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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

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is B

Explanation

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

Correct Answer is B

Explanation

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