A patient has been receiving chlorpromazine (Thorazine) for 2 years. Which of the following symptoms would lead the health care provider making a home visit to immediately call the pre-scriber?
a. Dry mouth and constipation
b. Dizziness upon standing
c. Sunburn after being out-of-doors for 30 minutes
d. Lip smacking and excessive tongue movements
ANS: D
Lip smacking and excessive tongue movements are signs of tardive dyskinesia, an adverse effect of antipsychotic drug therapy. The drug should immediately be discontinued if this occurs.
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You are caring for a patient who speaks a language different from your own. You recognize that special approaches for overcoming the language barrier would include which of the following? Select all that apply
a. Use clichés and jargon for a little humor b. Avoid defensive or offensive body language c. Use a different interpreter for each interaction d. Speak to the interpreter, rather than to the patient e. Provide reading material written in the appropriate language f. Use a culturally sensitive interpreter with fluency in health care terminology
The nurse is measuring central venous pressure readings for a client receiving fluid resuscitation. Prior to obtaining the reading, what priority nursing action is required?
A) Have the head of the bed at 90°. B) Ensure the level of the transducer is at the level of the right atrium. C) Ensure the transducer is above the level of the heart. D) Ensure the transducer is 2 inches below the level of the heart.
Which observation by the nurse indicates that an adolescent's cognitive thinking is developing at an expected level?
A) Adolescent says that all plastic remote controls break easily. B) Adolescent asks the mother to provide the sharp item needed to cut meat. C) Adolescent explains how working a part-time job will help pay for a car. D) Adolescent tells the parent that the dog moved the bicycle into the driveway.
Based on current evidence, the nurse who plans smoking cessation interventions for adolescent girls should focus on interventions directed toward
a. Obeying parents and reducing television viewing. b. Fostering generativity over self-absorption. c. Role overload, addiction counseling, and depression. d. Weight management, self-esteem, and stress management.