When you go to administer a client's dose of chlorpromazine (Thorazine), you note that he has developed a high fever and rapid heart rate. Which of the following actions would be BEST on your part?
a. Observe and give cool sponge baths.
b. Give medication and repeat vital signs in 4 hours.
c. Hold his medication and call the provider.
d. Administer an anti-inflammatory prn drug.
C
If the client has developed a high fever and rapid heart rate, the best course of action would be to hold his medication and call the provider. The client may be suffering from neuroleptic malignant syndrome. Neuroleptic malignant syndrome is a possible side effect of all antipsychotic medications and has symptoms of fever, rigidity, tachycardia, hypertension, and decreased levels of consciousness.
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An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?
a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.
Which finding best indicates that a patient has a mental illness? The patient:
a. responds to rules, routines, and customs of a group. b. reports mood is consistently sad, discouraged, and hopeless. c. performs tasks attempted within the limits set by own abilities. d. is able to see the difference between the "as if" and the "for real."
What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?
a. Place an ice pack on the scrotal area. b. Place the child in an upright sitting position. c. Elevate the scrotum with a rolled washcloth. d. Place a warm moist pack to the scrotal area.
A patient has hearing loss. To communicate with the person, you need to do which of the fol-lowing?
a. State the topic of conversation first. b. Use long, open-ended statements. c. Shout when talking to the person. d. Discuss all of your ideas at once.