During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Keep the client's television on with the volume low

Insert an indwelling urinary catheter to minimize interaction with the client.

Consult the provider regarding administering a mild sedative on a schedule.

Move the client to a room near the nurses' station

Answer and Explanation

The Correct Answer is D

A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.

B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.

C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.

D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.

A. "You should administer the medication at bedtime." B. "Your child should avoid foods containing tyramine." C. "You should administer the medication after breakfast" D. "Your child should avoid excess sodium intake."

Correct Answer is C

Explanation

Choice A reason:

"You should administer the medication at bedtime." This statement is incorrect option. Administering methylphenidate at bedtime is not appropriate because it is a stimulant medication, and taking it in the evening could interfere with the child's ability to fall asleep and disrupt their sleep pattern.

"Your child should avoid foods containing tyramine. “This statement is incorrect option. Tyramine is not a concern with methylphenidate. Tyramine is associated with certain antidepressant medications, such as MAO inhibitors. Methylphenidate is not a MAO inhibitor, so there is no need for the child to avoid tyramine-containing foods.

Option C: "You should administer the medication after breakfast." This is the correct option. Administering methylphenidate after breakfast is a common practice because it allows the child to benefit from the medication during school hours when improved attention and focus are needed the most.

"Your child should avoid excess sodium intake." This statement is an incorrect option. Excess sodium intake is not directly related to methylphenidate use. However, it is generally a good idea for anyone, including children, to have a balanced and healthy diet, which may include monitoring sodium intake. But it is not specifically tied to the administration of methylphenidate.

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During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching?

Correct Answer is C

Explanation

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A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?