For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

less-restrictive alternatives have been tried without success

the medication will make the work of the staff easier or safer

the client is willing to accept the medication

the clients behavior indicates possible danger to self, others or the environment

Answer and Explanation

The Correct Answer is D

A. Less-restrictive alternatives have been tried without success: While it is important to explore less-restrictive alternatives before resorting to medication, the immediate concern is the client's safety and the safety of others. If the client's behavior poses a significant risk, prompt intervention may be necessary.

B. The medication will make the work of the staff easier or safer: While staff safety is important, the primary consideration for administering a prn dose of Haloperidol is the clinical need based on the client's behavior and potential danger to themselves, others, or the environment.

C. The client is willing to accept the medication: Client willingness to accept medication is relevant for promoting collaboration in treatment, but the urgency in administering a prn dose is often based on the client's behavior and the level of risk they pose.

D. The client's behavior indicates possible danger to self, others, or the environment: This is the most critical factor in determining the need for a prn dose. If a client's behavior poses a significant risk, such as aggression, violence, or extreme agitation, administering a prn dose of medication may be necessary to ensure safety and prevent harm.

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Correct Answer is A

Explanation

A. A nurse asks a client if they have any cultural beliefs the nurse needs to be aware of: This example demonstrates cultural competence as the nurse is actively seeking information about the client's cultural beliefs, practices, and preferences. It reflects an understanding that cultural factors can influence healthcare and the client-nurse relationship.

B. A nurse tells a client about the nurse's own cultural background: While sharing cultural information can be a part of building rapport, the focus of cultural competence is on understanding and respecting the client's cultural background, not necessarily sharing the nurse's own cultural background.

C. A nurse observes a client's actions and reports they do not see any cultural practices: This approach is limited, as cultural practices may not always be visible or evident in a clinical setting. Cultural competence involves actively seeking information from the client rather than making assumptions based on observations.

D. A nurse checks a client's chart for any notes on culture: While reviewing a client's chart for cultural information is part of cultural competence, it is not a complete approach. Direct communication with the client about their cultural beliefs and preferences is essential for a comprehensive understanding.

A. Risk for suicide B. Risk for injury C. Powerlessness D. Risk for imbalance nutrition

Correct Answer is A

Explanation

A. Priority. The patient is exhibiting severe depression, weight loss, and expressing hopelessness, which are all indicators of an increased risk for suicide. Assessing and addressing the risk for suicide is crucial to ensuring the safety and well-being of the patient.

B. Incorrect. While the patient may be at risk for injury due to factors such as poor nutrition and potential self-harm, the immediate concern in this case is the risk for suicide, given the patient's severe depression and expressed hopelessness.

C. Incorrect. Powerlessness may be a relevant nursing diagnosis for individuals experiencing depression, but the immediate concern in this case is the risk for suicide. Addressing the patient's sense of powerlessness can be part of the broader care plan, but it's not the priority.

D. Incorrect. While the patient has experienced significant weight loss, the priority at this time is addressing the risk for suicide. Once the immediate safety concern is addressed, nutritional concerns can be addressed as part of the overall care plan.

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For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is describing the concept of cultural competence to a newly licensed nurse. Which of the following examples should the nurse include?

Correct Answer is A

Explanation

A newly admitted patient is severely depressed, lost 20 pounds over the past month, and expresses hopelessness for the future. Select the priority nursing diagnosis

Correct Answer is A

Explanation

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

How does a democratic form of self-government in the milieu contribute to client therapy?

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving:

A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

A nurse is reviewing the medical record of a client who has a new prescription for clozapine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to clozapine?

Within the nurse's scope of practice, which function is exclusive to the advanced practice psychiatric nurse?