A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?

Determine if the client is experiencing command hallucinations.

Arrange for the client to have consistent staff assignments.

Administer lorazepam to the client.

Use the client's name when talking to him.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.

Choice B rationale:

Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.

Choice C rationale:

Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.

Choice D rationale:

Using the client's name is respectful and helpful, but it is not the priority action in this scenario.

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Correct Answer is B

Explanation

Choice A rationale:

Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.

Choice B rationale:

Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.

Choice C rationale:

Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.

Choice D rationale:

Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.

A. Chlamydia is treated using antiviral medications. B. Clients can resume intercourse once treatment has started. C. A chlamydia infection is often asymptomatic in female clients. D. Female clients who are at risk for chlamydia should be screened every 2 years.

Correct Answer is C

Explanation

Choice A rationale:

Chlamydia is a bacterial infection, so it is treated with antibiotics, not antiviral medications.

Choice B rationale:

Clients should abstain from sexual intercourse until the treatment course is completed to prevent transmission.

Choice C rationale:

Chlamydia infections are often asymptomatic in both males and females, which can lead to undiagnosed and untreated infections. Routine screening is important to detect and treat infections early.

Choice D rationale:

The recommended frequency for chlamydia screening in female clients at risk is annually, not every 2 years.

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A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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