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 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.

A. A client who has a productive cough and an oral temperature of 36° C (96.8°F). B. A client who reports tingling in the fingers following a thyroidectomy. C. A client who is in a long leg cast and has +2 pedal pulses bilaterally. D. A client who has dark, foul-smelling urine and a urine output of 320 mL in the last 8 hr

Correct Answer is B

Explanation

A. A client who has a productive cough and an oral temperature of 36° C (96.8°F): A normal temperature and stable vital signs indicate that this client’s condition is not immediately life-threatening. Assessment is important but not the priority.

B. A client who reports tingling in the fingers following a thyroidectomy: Tingling in the fingers may indicate hypocalcemia from potential injury or removal of the parathyroid glands during thyroidectomy. This is an acute complication that can lead to tetany or cardiac dysrhythmias, making it the highest priority.

C. A client who is in a long leg cast and has +2 pedal pulses bilaterally: Adequate pedal pulses indicate good circulation. While monitoring for neurovascular compromise is necessary, this client is currently stable.

D. A client who has dark, foul-smelling urine and a urine output of 320 mL in the last 8 hr: Oliguria and infection risk are concerning and require follow-up, but these findings do not pose an immediate threat compared with potential hypocalcemia after thyroid surgery.

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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?

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