The nurse manager of a community mental health treatment facility is establishing a policy for staff members to follow when administering antipsychotic medications. Which standard is most important for the nurse-manager to include in this policy?

Teach clients to be aware that dryness of the mouth can occur with the use of antipsychotic drugs.

Monitor all clients receiving antipsychotic drugs for indications of tardive dyskinesia.

Ensure that all clients treated with antipsychotic drugs receive prompt renewals as needed.

Document all client therapeutic serum levels that relate to antipsychotic medications.

Answer and Explanation

The Correct Answer is B

Choice A: Teaching clients about the potential side effects of antipsychotic drugs is important, but it is not the most critical aspect of medication administration policy. Monitoring for side effects and adverse reactions is typically the responsibility of healthcare providers and nursing staff.

Choice B: Monitoring all clients receiving antipsychotic drugs for indications of tardive dyskinesia is a crucial standard to include in the policy. Tardive dyskinesia is a serious side effect associated with long-term use of antipsychotic medications, and early detection and intervention are essential to prevent its progression.

Choice C: Ensuring that all clients treated with antipsychotic drugs receive prompt renewals as needed is important for continuity of care, but it is not the primary focus of a policy for administering antipsychotic medications.

Choice D: Documenting all client therapeutic serum levels related to antipsychotic medications is relevant but may not apply to all clients receiving these medications. Monitoring for side effects and adverse reactions is generally more universally applicable and critical to patient safety.

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Correct Answer is D

Explanation

Choice A: Nasogastric tube insertion may be indicated in the management of a client with peptic ulcer disease (PUD) to assess bleeding, relieve gastric distention, or administer medications. However, in this scenario, the client's presentation with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia suggests a potentially life-threatening condition that requires immediate intervention beyond nasogastric tube insertion.

Choice B: Iced saline lavage is not a standard procedure for managing peptic ulcer disease (PUD) or its complications. It is not the immediate intervention required for the client's presentation.

Choice C: Administration of pantoprazole (Protonix) IV, a proton pump inhibitor, is a relevant intervention for managing peptic ulcer disease (PUD), but it may not be the most immediate action needed for a client with sudden severe abdominal pain, hypotension, and tachycardia. More urgent interventions are required.

Choice D: Emergency abdominal surgery is the most appropriate and immediate intervention for a client with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia. These signs and symptoms may indicate a perforated peptic ulcer, which is a surgical emergency requiring prompt exploration and repair of the perforation to prevent peritonitis and sepsis.

A. Impaired cognition. B. Memory loss. C. Mood alterations. D. Hearing loss.

Correct Answer is C

Explanation

Choice A: Impaired cognition is not a common manifestation of Cushing's syndrome. Cushing's syndrome is primarily characterized by hormonal imbalances and physical symptoms.

Choice B: Memory loss is not a common manifestation of Cushing's syndrome. The syndrome is more associated with hormonal and metabolic disturbances.

Choice C: Mood alterations, including irritability, anger, and emotional instability, are common manifestations of Cushing's syndrome. These mood changes can be attributed to the hormonal imbalances and physiological stress associated with the condition.

Choice D: Hearing loss is not a recognized symptom of Cushing's syndrome. Mood alterations and physical changes are more typical.

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The nurse manager of a community mental health treatment facility is establishing a policy for staff members to follow when administering antipsychotic medications. Which standard is most important for the nurse-manager to include in this policy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The practical nurse (PN) overhears a female client with Cushing's syndrome tell her family in a very loud and angry voice to leave her room and not to come back. The response by the PN is based on recognizing which common manifestation of the syndrome?

Correct Answer is C

Explanation

A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?

The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action should the nurse implement first?

The nurse is helping develop a meal plan based on nutritional guidelines for a 73-year-old client being discharge to home with the client's 65- year-old spouse. Which statement best indicates an understanding of the nutritional guidelines when planning meals by the two spouses?

During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?

The nurse is performing a nutritional assessment on a client who is professional dancer. Which issue reported by the client should alert the nurse to perform further assessment?

Which client is at greatest risk for aspiration?

Which statement by an adolescent client with acute osteomyelitis in the right leg indicates the best understanding of the appropriate activity level after discharge?

The nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which intervention is most important for the nurse to include in the client's plan of care?