- (Topic 5)
For the past several months, an elderly female client with Alzheimer??s disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
Correct Answer:
A
(A) Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. (B) Although mild tremors are an early sign of Parkinson??s disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimer??s disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects.
- (Topic 6)
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, ??Something is wrong. This is like my labor.?? Which reply by the nurse identifies the physiological response of the client?
Correct Answer:
C
(A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.
- (Topic 1)
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, ??My doctor is in love with me and wants to marry me.?? This client is using which of the following defense mechanisms?
Correct Answer:
B
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one??s thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
- (Topic 2)
The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
Correct Answer:
C
(A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first.
- (Topic 6)
A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is:
Correct Answer:
A
(A) Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the client should go to the ED for catheterization. (B, C, D) This choice is a symptom of BPH, but it is not serious or life threatening.