Which of the following questions would the nurse ask a woman to assess for hyperprolactinemia as a side effect of an antipsychotic medication?
1. Are you having trouble sitting still?
2. Are you constipated?
3. Are you having any discharge from your breasts?
4. Do you have a dry mouth?
3
Rationale: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.
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An unconscious patient requires mouth care every 2 hours. Before attempting mouth care, the nurse should first do which of the following?
a. Assess the patient for a gag reflex. b. Position the patient in a prone position. c. Have an operational suction machine nearby. d. Retract the upper and lower teeth with a padded tongue blade.
Which of the following is appropriate information for the nurse to provide to the patient who is scheduled for foot surgery?
A) Wear snug-fitting footwear postoperatively to decrease swelling. B) When experiencing discomfort in the foot, massage it. C) Full weight bearing on the affected foot postoperatively is necessary to increase circulation. D) Apply ice packs intermittently to decrease pain.
To find out how much alcohol a patient uses, a nurse asks about which of the following?
A. Quantity of alcohol consumed B. Frequency of alcoholic beverage consumption C. Duration of use D. All of the above
Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take?
1. Answer questions quickly and try to divert her attention to other subjects. 2. Review the documentation of the birth experience and discuss it with her. 3. Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience. 4. Submit a referral to Social Services because of possible obsessive behavior.