The nurse is continuing to assist in the care of the client.
Complete the following sentence by using the lists of options.
The nurse should reinforce teaching with the client to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Rationale for correct choices:
• Monitor body temperature: Paliperidone, an antipsychotic, can increase the risk of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening condition characterized by hyperthermia, muscle rigidity, and altered mental status. Teaching the client to monitor body temperature helps with early recognition of NMS and timely intervention.
• Report sore throat: Paliperidone can cause hematologic adverse effects, including leukopenia, neutropenia, and agranulocytosis. A sore throat may be an early sign of infection due to low white blood cell counts. Reinforcing the need to report symptoms like sore throat ensures prompt evaluation and prevents serious complications.
Rationale for incorrect choices:
• Anticipated increased bruising: Although some antipsychotics may rarely affect platelet function, paliperidone is not commonly associated with increased bruising. This is not a primary teaching point for the client. Monitoring for bruising is less critical than monitoring for signs of infection or NMS.
• Stop taking contraceptive medication: There is no evidence that paliperidone interacts with contraceptives in a way that requires discontinuation. Advising the client to stop contraceptive medication is unnecessary and could place the client at risk for unintended pregnancy.
• Expect weight loss: Paliperidone is more commonly associated with weight gain rather than weight loss. Counseling the client about expecting weight loss would be inaccurate and could mislead them regarding lifestyle and dietary management.
• Follow a low-sodium diet: Paliperidone does not require sodium restriction. Low-sodium diet recommendations are not indicated unless the client has a comorbid condition like hypertension or heart failure. This is unrelated to the medication’s primary safety concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Encourage prolonged dangling before ambulation: While dangling at the bedside can help prevent orthostatic hypotension, the client is already ambulating independently without reported dizziness or hypotension. Prolonged dangling is unnecessary and does not address the current issues of urinary discomfort and bowel cramping.
B. Encourage oral fluid intake: Adequate hydration helps maintain urine flow, prevent catheter obstruction, and support bowel function. Encouraging fluids also helps dilute urine, reducing bladder irritation and the risk of infection, which is especially important post-prostatectomy.
C. Assist the client with a sitz bath: A sitz bath can relieve perineal discomfort, reduce pain, and promote relaxation of the pelvic muscles. Given the client’s bladder fullness and postoperative cramping, this noninvasive intervention helps improve comfort and facilitate urination.
D. Irrigate indwelling catheter with 500 mL of fluid: Routine irrigation with such a large volume is not recommended and may cause trauma or introduce infection. Catheter irrigation should only be performed according to provider prescription and typically with small, prescribed amounts.
E. Administer an enema: The client reports only a single hard, painful bowel movement, and routine enema administration is not indicated. Enemas should be reserved for severe constipation or impaction, and inappropriate use can cause irritation or fluid shifts.
Correct Answer is B
Explanation
A. "The grieving process should be complete within 1 year.": Grieving does not follow a strict timeline and can vary greatly among individuals. Setting a fixed timeframe can create unrealistic expectations and may invalidate the family’s ongoing emotional experience.
B. "Anger toward the health care staff is expected.": Families may experience anger, frustration, or guilt during the grief process, including feelings directed at healthcare providers. Normalizing this reaction helps families understand that these emotions are a typical part of coping with terminal illness.
C. "The stages of grief occur in sequential order": Grief is not always linear, and individuals may move back and forth between stages or experience multiple stages simultaneously. Emphasizing sequential order can misrepresent the fluid nature of grieving.
D. "Anticipatory grieving prolongs the grief process": Anticipatory grieving allows families to emotionally prepare for a loved one’s death and can facilitate coping, rather than prolong grief. It is a healthy aspect of the grieving process, not a negative one.
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