Following three days of nausea, vomiting, and diarrhea, an older adult is admitted with severe dehydration. After two attempts, the nurse secured venous access using a 24-gauge IV catheter and began infusing 0.9% normal saline at 150 mL/hour. Minutes later, the client reports pain at the IV site. Which intervention should the nurse implement first?

Assess the IV site for blood return.

Stop the 0.9% normal saline infusion.

Establish IV access in a different extremity.

Select a different gauge IV needle.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing blood return checks patency, but pain suggests infiltration or phlebitis, where saline leaks into tissues. Stopping the infusion prevents further tissue damage, as extravasation causes swelling or necrosis, especially in dehydrated elderly clients, making assessment secondary to halting infusion.

Choice B reason: Stopping the saline infusion is the priority, as pain at the IV site suggests infiltration or phlebitis, with fluid irritating tissues or veins. Halting infusion prevents damage, allowing safe assessment and management, critical in fragile elderly veins, ensuring no further harm during rehydration.

Choice C reason: Establishing new IV access is necessary post-infiltration but not first. Pain indicates ongoing tissue irritation from saline leakage, requiring immediate infusion cessation to prevent damage. Stopping the infusion ensures safety before reattempting access, critical in dehydrated patients needing fluid replacement.

Choice D reason: Selecting a different gauge needle is irrelevant, as the 24-gauge catheter is placed, and pain indicates infiltration, not size. Stopping the infusion prevents extravasation, which risks compartment syndrome in elderly clients, making this less immediate than halting the infusion for safety.

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Correct Answer is A

Explanation

Choice A reason: Avolition in schizophrenia is lack of motivation for goal-directed tasks, linked to prefrontal dopamine deficits. Performing activities of daily living (e.g., hygiene) shows improved motivation, achieving the goal. This reflects enhanced frontal lobe function, addressing the negative symptom of avolition, critical for functional recovery in schizophrenia.

Choice B reason: Explaining answers to open-ended questions shows cognitive ability, not motivation. Avolition impairs initiative for tasks like self-care, not verbal skills. Schizophrenia’s negative symptoms reduce drive, and this behavior does not address the motivational deficit targeted, making it less relevant than performing daily activities.

Choice C reason: Reporting enjoyment suggests improved affect but not motivation. Avolition involves initiating tasks, not emotional response. Performing daily activities directly demonstrates overcoming avolition, a negative symptom of reduced drive, aligning with the goal of enhancing goal-directed behavior in schizophrenia, making this less indicative.

Choice D reason: Sharing a story indicates social engagement, impaired in schizophrenia but not specific to avolition, which affects motivation for routine tasks. Performing daily activities directly shows improved initiative, addressing the treatment goal’s focus on overcoming dopamine-related motivational deficits, making social sharing less relevant.

A. Discuss checking the time frequently. B. Ask the client why she checks the locks. C. Plan a list of activities to be carried out daily. D. Determine the type and size of the locks.

Correct Answer is C

Explanation

Choice A reason: Discussing time-checking does not address compulsive lock-checking, likely obsessive-compulsive disorder (OCD), driven by serotonin dysregulation causing intrusive fears. Time management is unrelated to compulsions. Planning activities reduces idle time, distracting from OCD behaviors, addressing the neurobiological basis more effectively.

Choice B reason: Asking why the client checks locks may heighten anxiety in OCD, as compulsions arise from irrational fears, not logic, via cortico-striatal-thalamic dysfunction. This may reinforce obsessions. Activity planning distracts from compulsions, offering a therapeutic approach to improve function, making questioning less effective.

Choice C reason: Planning daily activities structures time, reducing compulsive lock-checking in OCD, where obsessive fears disrupt function. Engaging tasks modulate serotonin, distracting from cortico-striatal overactivity, improving behavioral control. This addresses the disorder’s impact, enhancing functionality by minimizing compulsion opportunities, making it the best action.

Choice D reason: Determining lock type is irrelevant to OCD’s compulsive checking, rooted in neurobiological fear responses, not lock characteristics. This does not address serotonin imbalance. Activity planning redirects focus to structured tasks, reducing compulsions, making lock assessment ineffective for managing the client’s behavior.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, “Improvement in avolition prior to discharge.” Which behavior demonstrates achievement of this goal to the nurse?

Correct Answer is A

Explanation

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Correct Answer is C

Explanation

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen per nasal cannula at 3 L/minute, the nurse observes a red macular rash developing on the client’s right cheek. Which intervention should the nurse implement?

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?