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 C

Explanation

A. The urinary meatus is the external opening of the urethra and is not the source of the infection in this case.

B. The client's bed is not a direct reservoir for the infection, although poor hygiene practices can contribute to contamination.

C. Catheter tubing can harbor bacteria if not properly managed, leading to urinary tract infections. Prolonged periods without proper drainage can allow bacteria to multiply.

D. The client's bladder can become infected due to bacteria introduced via the catheter tubing, but it is not the initial reservoir.

Correct Answer is "\"\\\"{\\\\\\\"xRanges\\\\\\\":[215.828125,250.828125],\\\\\\\"yRanges\\\\\\\":[93.5,128.5]}\\\"\""

Explanation

In the assessment of a client with a head injury, the nurse should be vigilant for signs of rhinorrhea, which could indicate a leakage of cerebrospinal fluid (CSF).

The nurse should observe for a clear, watery discharge from the nose, which is a characteristic sign of CSF rhinorrhea.

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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 client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection. In evaluating the cause of the infection, what should the nurse identify as the infection reservoir?

Correct Answer is C

Explanation

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

Correct Answer is "\"\\\"{\\\\\\\"xRanges\\\\\\\":[215.828125,250.828125],\\\\\\\"yRanges\\\\\\\":[93.5,128.5]}\\\"\""

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Exhibits The nurse is considering the possible etiology of the client's symptoms. Click to indicate if the listed assessment findings are consistent with benign prostate hyperplasia, urinary tract infections, or prostatitis. Each column must have at least one response option selected.

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

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is best for the nurse to implement?

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.