The nurse continues to assist in the care of the client.

2030: Medication Administration Record.

Day 5, 0700: Ziprasidone 20 mg IM left deltoid muscle. Paliperidone 6 mg PO.

Nurses' Notes.

2015: 2030: Client appears disheveled with matted hair and stained clothing. Attempting to get out of handcuffs. The client states, "I have to. get out of here. I hear the helicopters. They are coming to get me!” Client able to state name, but not date. They believe they are in. a laboratory, run by the doctors who have been prescribing their medications.

When asked about their medical history, they reply, "My name is Jamie, and you are the devil.”

2145: Reviewed police report: Client found attempting to break through a window at the clinic downtown. When approached,. client yelled and tried to hit the officer with the stick they were using. "Get away, I have to get the notes, they are trying to. poison me.” Client appears to be responding to internal stimuli but is less outwardly agitated.

Changed into hospital scrubs with encouragement.

Handcuffs removed by police and 1:1 sitter at. The nurse is collecting data from the client 5 days after admission.

For each finding, click to specify whether the finding indicates the client's condition has improved or declined.

Response to other clients

Sleep patterns

Hygiene patterns

Interaction with the nurse

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Here are some possible answers: Response to other clients: This finding could indicate that the client’s condition has improved if they are more cooperative and respectful of others, or that it has declined if they are more hostile and paranoid of others. Sleep patterns: This finding could indicate that the client’s condition has improved if they are sleeping more regularly and peacefully, or that it has declined if they are sleeping less or having nightmares.

Hygiene patterns: This finding could indicate that the client’s condition has improved if they are taking care of their personal hygiene and appearance, or that it has declined if they are neglecting or refusing to do so. Interaction with the nurse: This finding could indicate that the client’s condition has improved if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale:

While music therapy can be a helpful adjunct for pain management, it is not a replacement for all pain medications. Pain management should be individualized, and the statement that music therapy alone will eliminate the need for all medication is not accurate.

Choice B rationale:

Discontinuing music therapy when the patient is no longer responsive may not be the best approach. Music therapy can still provide comfort and support even if the patient is not responsive in the traditional sense. It should be continued if it benefits the patient.

Choice C rationale:

Playing music is not intended to increase alertness but rather to provide comfort and relaxation. This statement reflects a misunderstanding of the purpose of music therapy in pain management.

Choice D rationale:

This statement correctly indicates an understanding of the purpose of music therapy. Music can distract the patient from pain and provide a sense of comfort and relaxation without completely eliminating awareness of pain.

A. "I will carry my baby to the nursery.” B. "I can take my baby to the lobby to visit family.” C. "I will have an identification band that matches the one my baby wears.” D. "I can remove my security band to give it to a family member.”

Correct Answer is C

Explanation

Choice A rationale:

Carrying the baby to the nursery may not align with facility security measures. Typically, hospitals have strict protocols for baby transport within the facility, including the use of identification bands.

Choice B rationale:

Taking the baby to the lobby to visit family may also not be in line with security measures. Visitors should typically come to the designated patient areas rather than taking the baby to the lobby.

Choice C rationale:

Having an identification band that matches the one the baby wears is the correct understanding of facility security measures. This ensures proper identification of the baby and helps prevent infant abduction or mix-ups.

Choice D rationale:

Removing the security band to give it to a family member is not in line with security measures. The baby's identification band should remain intact at all times to ensure proper identification and security.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management.Which of the following statements by the partner indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a new mother about facility security measures.Which of the following statements by the mother indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who presents to the labor and delivery unit. Exhibits The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.

A nurse is providing care to a client who is immunocompromised.Which of the following should the nurse identify as a possible source of infection?

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client. Exhibits Data Collection Findings. For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis.Into which of the following positions should the nurse assist the client?

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

A nurse is reinforcing teaching with a client who is about to undergo surgery.Which of the following statements about informed consent should the nurse include in the teaching?

A nurse in a provider's office is collecting data from a client who has candidiasis.Which of the following findings should the nurse expect?