Ati Nclex Rationales

ATI NCLEX RATIONALES 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. MYOCD 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.