A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety?
His wife has minimal family support.
His wife works from home in telecommunication.
The client smokes one pack of cigarettes per day.
The client has worked nightshift his entire life.
The Correct Answer is C
a. His wife has minimal family support: While limited family support might affect the caregiver’s burden, it does not directly imply immediate safety concerns for the client.
b. His wife works from home in telecommunication: Working from home can be beneficial as she is physically present to assist the client.
c. The client smokes one pack of cigarettes per day. Smoking increases the risk of cardiovascular events and other health complications, which can exacerbate symptoms of vascular NCD and pose safety risks.
d. The client has worked nightshift his entire life. While working night shifts might affect his sleep patterns, it does not pose an immediate safety concern compared to the risk associated with smoking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.
Correct Answer is C
Explanation
a. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach: Benztropine is an anticholinergic medication used to manage the extrapyramidal side effects (EPS) of antipsychotics. However, it's important to consult the healthcare provider before administering any additional medications.
b. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect: Increasing the dose of Haloperidol might worsen the tardive dyskinesia symptoms.
c. Hold the dose of Haloperidol and notify the healthcare provider. (Correct) Haloperidol is an antipsychotic medication with a known side effect of tardive dyskinesia, which manifests as involuntary facial and body movements. Stopping the medication and informing the provider is crucial to determine the best course of action, which might involve dose adjustment or switching medications
d. Explain to the client that the side effects should diminish in one to two weeks: Tardive dyskinesia can be a persistent side effect, and reassurance without addressing the medication is not helpful.
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