A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Remain with the client.

Give to client a PRN sleeping medication,

Encourage the client to go back to bed.

Explore alternatives to pacing the floor with the client.

Answer and Explanation

The Correct Answer is A

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

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Correct Answer is C

Explanation

A. Bleeding:

Explanation: Bleeding is not a common adverse effect of haloperidol, which is an antipsychotic medication used to treat conditions like schizophrenia. Haloperidol primarily works on the central nervous system and is not known to directly cause bleeding issues.

B. Cataracts:

Explanation: Cataracts are not a common adverse effect of haloperidol either. While long-term use of some antipsychotic medications can lead to metabolic and endocrine disturbances, which might indirectly impact eye health, cataracts are not a direct and immediate concern with haloperidol use.

C. Dysrhythmias:

Explanation: Correct Answer. Haloperidol has the potential to cause cardiac-related adverse effects, including dysrhythmias (irregular heart rhythms). This is a particular concern in individuals who are predisposed to heart conditions or have other risk factors. The medication can prolong the QT interval, which is a measure of the time it takes for the heart's electrical system to recharge between beats. Prolonged QT interval can lead to serious and potentially life-threatening arrhythmias.

D. Pancreatitis:

Explanation: Pancreatitis is not a common adverse effect of haloperidol. Pancreatitis typically involves inflammation of the pancreas and can be caused by various factors such as gallstones, alcohol consumption, and certain medications. Haloperidol is not known to directly cause inflammation of the pancreas.

A. Brief Patient Health Questionnaire (Brief PHQ) B. Abnormal Involuntary Movements Scale (AIMS) C. Mental status examination (MSE) D. Scale for Assessment of Negative Symptoms (SANS)

Correct Answer is C

Explanation

A. Brief Patient Health Questionnaire (Brief PHQ):

The Brief PHQ is a screening tool used to assess symptoms of depression. While it may be relevant to assess mood and emotional well-being, it is not specific to evaluating cognitive functioning or cognitive disorders.

B. Abnormal Involuntary Movements Scale (AIMS):

The AIMS is used to assess involuntary movements, particularly in individuals taking antipsychotic medications. It is not directly related to assessing cognitive disorders.

C,. Mental status examination (MSE)

Explanation:

When admitting an older adult client with a suspected cognitive disorder, including a mental status examination (MSE) as part of the assessment is crucial. The MSE is a structured assessment of a client's current cognitive functioning, emotional state, and thought processes. It helps to evaluate memory, attention, language, perception, orientation, mood, and other cognitive and emotional domains.

D. Scale for Assessment of Negative Symptoms (SANS):

The SANS is used to assess negative symptoms in individuals with schizophrenia. It focuses on features such as affective blunting, alogia, anhedonia, and other negative symptoms. While it may provide important information about a client's mental state, it is not primarily used to assess cognitive disorders.

Assessing cognitive function is a key component when evaluating older adult clients for cognitive disorders such as dementia or other cognitive impairments. The MSE provides valuable information to guide diagnosis and treatment planning for these conditions.

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A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

Correct Answer is C

Explanation

A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

Correct Answer is C

Explanation

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