A nurse is planning care for a client who takes haloperidol for the treatment of schizophrenia. Which of the following should the nurse include in the plan of care?

Monitor the client for hypothermia.

Screen the client for tardive dyskinesia.

Check the client's weekly potassium level

Schedule the client for a 24-hr urine collection.

Answer and Explanation

The Correct Answer is B

A. Monitor the client for hypothermia: Hypothermia is not a typical adverse effect of haloperidol. The medication more commonly causes extrapyramidal symptoms and neuroleptic malignant syndrome, which may include hyperthermia rather than hypothermia.

B. Screen the client for tardive dyskinesia: Tardive dyskinesia is a serious, potentially irreversible extrapyramidal side effect associated with long-term use of antipsychotics such as haloperidol. Routine screening using tools like the Abnormal Involuntary Movement Scale (AIMS) is essential to detect early signs and adjust therapy as needed.

C. Check the client's weekly potassium level: Haloperidol does not typically affect potassium levels. Routine electrolyte monitoring is not indicated unless the client has other conditions or is taking medications that affect potassium.

D. Schedule the client for a 24-hr urine collection: A 24-hour urine collection is unrelated to haloperidol therapy. This test is used to assess kidney function or specific metabolic conditions and is not part of routine care for clients taking antipsychotics.

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Correct Answer is ["B","C","E"]

Explanation

A. Dermatitis: Dermatitis affects the skin and is not associated with an increased risk of pneumonia. While skin integrity issues can lead to infections, they do not directly predispose a client to respiratory infections like pneumonia.

B. Type II diabetes mellitus: Diabetes mellitus impairs immune function and increases susceptibility to infections, including pneumonia. Hyperglycemia can impair neutrophil function, reducing the body’s ability to fight bacterial respiratory infections.

C. Smoking history: Smoking damages the respiratory epithelium and impairs mucociliary clearance, increasing the risk of bacterial colonization and infection in the lungs. A long-term smoking history is a well-established risk factor for pneumonia.

D. Hypothyroidism: Hypothyroidism can slow metabolism and affect multiple organ systems but is not a direct risk factor for pneumonia. While severe hypothyroidism may influence respiratory function, it is not considered a primary predisposing condition.

E. COPD: Chronic obstructive pulmonary disease leads to compromised lung function, impaired clearance of secretions, and increased susceptibility to respiratory infections. COPD is a significant risk factor for developing pneumonia, particularly in the lower lobes.

F. Hypertension: Hypertension affects cardiovascular health but does not directly impair immune function or pulmonary defenses. It is not considered a risk factor for pneumonia.

A. Brush teeth immediately after eating B. Lay down for 30 min after meals. C. Drink 12 oz of water with each meal. D. Eat a dry carbohydrate before getting out of bed.

Correct Answer is D

Explanation

A. Brush teeth immediately after eating: Brushing teeth right after eating may worsen nausea and vomiting due to stimulation of the gag reflex or irritation of the oral mucosa. It is better to rinse the mouth with water or a mild mouthwash instead.

B. Lay down for 30 min after meals: Lying down after eating can exacerbate nausea and increase the risk of reflux. Remaining upright after meals promotes gastric emptying and reduces symptoms of morning sickness.

C. Drink 12 oz of water with each meal: Drinking large amounts of fluid during meals can distend the stomach and worsen nausea. Small, frequent sips of fluids between meals are more effective in maintaining hydration without increasing discomfort.

D. Eat a dry carbohydrate before getting out of bed: Consuming a dry carbohydrate, such as toast or crackers, before rising in the morning helps stabilize blood sugar levels and reduce nausea associated with morning sickness. This is a safe and effective strategy for managing early pregnancy nausea.

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A nurse is planning care for a client who takes haloperidol for the treatment of schizophrenia. Which of the following should the nurse include in the plan of care?

Nursing Test Bank

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