Strategy: “MOST important” indicates that this is a priority question.

(1) may be part of follow-up

(2) correct–means of transmission of chlamydia may or may not have been made

clear to both

partners; nurse should assess this first; is a sexually transmitted disease

(3) most cultures used today have few false positives

(4) would be done later in the nursing assessment

77. A 59-year-old woman with bipolar disorder is receiving haloperidol

(Haldol) 2 mg PO tid. She tells the nurse, “Milk is coming out of my

breasts.” Which of the following responses by the nurse is BEST?

1. “You are seeing things that aren’t real.”

2. “Why don’t we go make some fudge.”

3. “You are experiencing a side effect of Haldol.”

4. “I’ll contact your physician to change your medication.”

Strategy: The topic of the question is unstated.

(1) hallucinations usually not seen with patients with bipolar disorder, seen with

psychotic disorders

(2) assumption that patient just wants attention

(3) correct–side effects include galactorrhea (excessive or spontaneous flow of milk),

lactation, gynecomastia (excessive growth of male mammary glands)

(4) indicates a side effect, not effectiveness of medication

78. A client returns from surgery after having a cholecystectomy, and there

is an order for antiembolism stockings. Which of the following would be

appropriate teaching regarding wearing the support stockings?

1. The client will need to wear the stockings when her legs cramp.

2. The stockings should be worn the entire time the client is in the hospital.

3. The stockings should be put on in the evening prior to going to bed.

4. After the client gets out of bed and walks around, she should put on the stockings.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?

(1) antiembolism stockings should be worn to prevent any discomfort, and to

increase the blood

flow

(2) correct–stockings should be worn the entire time client is in the hospital; should

be removed for baths and replaced after the skin is dry, and before the client gets

out of bed

(3) stockings should be worn during the day and when client is nonambulatory

(4) stockings should be applied before getting out of bed

79. A client is scheduled for a left lower lobectomy. The physician has

ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine

that the medication is appropriate if the client displays which of the

following symptoms?

1. Agitation and decreased level of consciousness.

2. Lethargy and decreased respiratory rate.

3. Restlessness and increased heart rate.

4. Hostility and increased blood pressure.