A health care provider has ordered vital signs every 4 hours.
The client’s 8:00 AM temperature was 99° F (37.2° C).
At 10 AM, the client reported chills.
A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?
Interdependent.
Dependent.
Collaborative.
Independent.
The Correct Answer is D
Independent. An independent nursing intervention is an action that a nurse can perform by themselves, without any management from a doctor or another discipline.
Taking the client’s temperature again is an example of an independent nursing intervention because it does not require a physician’s order or collaboration with other health care professionals.
Choice A is wrong because an interdependent nursing intervention is an action that requires collaboration or consultation with other health care professionals.
Taking the client’s temperature again does not involve working with other disciplines.
Choice B is wrong because a dependent nursing intervention is an action that requires an order from a physician or another health care provider.
Taking the client’s temperature again does not require a physician’s order.
Choice C is wrong because a collaborative nursing intervention is an action that involves working with other health care professionals to provide patient care.
Taking the client’s temperature again does not require collaboration with other disciplines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement suggests that the client needs further teaching because haloperidol is a medication that needs to be taken regularly and consistently to prevent relapse of symptoms related to schizophrenia. Stopping the medication abruptly can cause withdrawal effects and worsen the condition.
Choice B is wrong because it shows that the client understands the potential interaction between alcohol and haloperidol, which can increase the risk of sedation, drowsiness, and low blood pressure.
Choice C is wrong because it indicates that the client has realistic expectations about the onset of action of haloperidol, which can take several days or weeks to show improvement of symptoms.
Choice D is wrong because it demonstrates that the client is aware of the possible side effect of photosensitivity caused by haloperidol, which can make the skin more prone to sunburn and damage.
Haloperidol is an antipsychotic drug that works by blocking dopamine receptors in the brain. It is used to treat symptoms such as hallucinations, delusions, paranoia, and disorganized thinking in schizophrenia and other psychotic disorders. The normal dosage range for haloperidol is 0.5 to 20 mg per day, depending on the severity of the condition and the response to treatment. Some of the common side effects of haloperidol include extrapyramidal symptoms (EPS), such as muscle stiffness, tremors, restlessness, and abnormal movements; neuroleptic malignant syndrome (NMS), which is a rare but serious condition characterized by fever, muscle rigidity, altered mental status, and autonomic instability; and tardive dyskinesia (TD), which is a chronic movement disorder that involves involuntary movements of the tongue, lips, face, and limbs. Haloperidol can also cause weight gain, dry mouth, blurred vision, constipation, dizziness, insomnia, and sexual dysfunction.
Haloperidol should be used with caution in patients with cardiovascular disease, liver disease, seizure disorder, diabetes mellitus, thyroid dysfunction
Correct Answer is D
Explanation
This question evaluates the client’s understanding of the most important infection control measure for hepatitis A, which is hand hygiene. Hepatitis A is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person’s feces.
Washing hands after using the toilet can prevent the spread of the virus to others and to oneself.
Choice A is wrong because eating raw shellfish is not a risk factor for hepatitis A unless the shellfish is contaminated with the virus from polluted water.
Choice B is wrong because cooking pork products does not affect hepatitis A transmission, as the virus is not found in pork or other meats.
Choice C is wrong because traveling out of the country is not a risk factor for hepatitis A unless the destination has poor sanitation and hygiene conditions.
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