A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

"I haven't had a drink of alcohol since I started taking these injections."

"I spend several hours a day outside gardening when it's sunny."

"I check my blood pressure once a week.

"I chew sugar-free gum several times daily."

Answer and Explanation

The Correct Answer is B

A.   This statement indicates that the client has abstained from alcohol while on haloperidol decanoate. This is a positive statement and shows compliance with recommendations, as alcohol can interact with medications and affect their effectiveness or cause adverse reactions. There is no immediate concern with this statement.
B.   Haloperidol can increase sensitivity to sunlight (photosensitivity). Spending several hours outside gardening in the sun could potentially increase the risk of sunburn or other skin reactions due to photosensitivity. The nurse should address this statement by educating the client about the need to use sunscreen, wear protective clothing, and avoid prolonged sun exposure, especially during peak sunlight hours.
C.   Regular monitoring of blood pressure is generally recommended for clients taking haloperidol, as it can occasionally cause hypotension (low blood pressure) as a side effect. Checking blood pressure once a week is a reasonable frequency, but the nurse should ensure that the client understands the signs and symptoms of hypotension and knows when to seek medical attention if blood pressure readings are abnormal.
D.   Chewing sugar-free gum is generally not contraindicated while taking haloperidol. However, if the gum contains caffeine or other stimulants, it could potentially exacerbate certain side effects of the medication, such as tremors or restlessness. The nurse should inquire further about the type of gum being used and educate the client about potential interactions or side effects.

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Correct Answer is B

Explanation

A. This response could come across as blaming or judgmental. It implies that the client made a mistake by not seeking help, which can exacerbate feelings of guilt or shame. It does not promote an open dialogue or supportive environment.
B. This response demonstrates empathy and a willingness to understand the client's emotional state leading up to the suicide attempt. It encourages open communication about the client's feelings and experiences, which is crucial for assessment and intervention planning.
C. This response suggests that the nurse is making assumptions about the client's emotions without allowing the client to express themselves fully. While guilt may be a common emotion after a suicide attempt, it's important for the nurse to first listen to the client's own description of their feelings.
D. This response minimizes the seriousness of the client's experience and emotions. It may invalidate the client's feelings of distress or despair that led to the suicide attempt. Such a response does not acknowledge the gravity of the situation or provide the necessary support.

A. Witness the client signing the form. B. Discuss alternative treatment options with the client. C. Determine the client is competent to give consent. D. Discuss the benefits of ECT with the client.

Correct Answer is A

Explanation

A. One of the nurse's responsibilities during the informed consent process is to witness the client signing the consent form. This ensures that the client voluntarily agrees to undergo ECT after receiving adequate information about the procedure, its risks, benefits, and alternatives. By witnessing the signature, the nurse confirms that the client's consent is documented appropriately and legally.
B. Nurses may provide general information about ECT and its alternatives, but the detailed discussion about treatment options and their implications usually occurs during the consultation with the provider.
C. Determining if a client is competent to give consent is a legal determination typically made by a healthcare provider or a legal representative, not the nurse.
D. It is not the nurse's role to discuss the specific benefits of ECT, as these discussions are the responsibility of the healthcare provider leading the client's care.

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A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?

Correct Answer is A

Explanation

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