1. Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional antipsychotic
medications. The client should be monitored for changes in vital signs, tachycardia, and ECG changes,
including prolonged QT interval, while taking haloperidol. There is a risk for cardiac arrest due to
torsades de pointes.
2. Body weight is the most reliable indicator of fluid loss for infants and young children.
3. Measles, mumps rubella (MMR) is correct. A 1-year-old child should receive the first of two doses of
the MMR vaccine.
Diphtheria, tetanus and acellular pertussis (DTaP) is incorrect. By 1 year of age, the child should
have already received three doses of DTaP: at 2 months, 4 months, and 6 months. The child should
receive a fourth dose at 15 months of age.
Varicella (VAR) is correct. A 1-year-old child should receive the first of two doses of the VAR vaccine.
Rotavirus (RV) is incorrect. A 1-year-old child should have received the RV vaccine in a two or three
dose series starting at 2 months of age.
Human papillomavirus (HPV4) is incorrect. A child should receive a three dose series of the HPV4
vaccine at 11 or 12 years of age.
4. The client has paralysis from the level of the defect down. In the majority of cases, this condition
affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent
emptying of the bladder can result in stasis and urinary tract infections.
5. Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a
second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an
artery, a vein, or the heart.
6. Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of antipsychotic
(haloperidol) medications that requires emergency medical intervention. Manifestations of NMS are
sudden and include changes in level of consciousness, seizures, and stupor.
7. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination
following delivery. Immunization during pregnancy is contraindicated because of possible injury to the
developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1
month.
8. Any adult who has a respiratory rate of over 30/min requires immediate attention. Additionally, this
patient is unconscious, which constitutes altered mental status. This client is the client he nurse should
care for first.
9. Plan the client's schedule to allow time for rituals. 10 . M YOCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels driven to
perform. This behavior can be a physical action or a mental act that is aimed at neutralizing anxiety or
distress. In the initial phase of treatment, the nurse should allow adequate time for the client to perform
rituals to help the client handle anxiety.
11. Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause
bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle
relaxation.
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