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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

The correct answer is ChoiceC.

Choice A rationale:Restricting fluid intake to 1 L per day is not recommended for a client with a urinary tract infection (UTI). Adequate hydration is essential for flushing out bacteria from the urinary tract and preventing further infections. Therefore, this choice is incorrect.

Choice B rationale:Taking the prescribed antibiotic until manifestations are gone is partially correct. It’s crucial for the client to complete the entire course of antibiotics, even if symptoms improve or disappear before the medication is finished. Stopping antibiotics early can lead to recurrent infections or antibiotic resistance. Therefore, this choice ispartially correct, but the instruction should be clarified to ensure the client understands the importance of completing the full course of antibiotics.

Choice C rationale:Wearing cotton underwear is recommended for clients with a UTI. Cotton is a breathable fabric that can help keep the area around the urethra dry, reducing the likelihood of bacterial growth. Therefore, this choice is correct.

Choice D rationale:Drinking orange juice daily for 3 to 4 weeks is not specifically recommended for a client with a UTI. While vitamin C can help inhibit bacterial growth, orange juice is high in sugar, which can promote bacterial growth. It’s more beneficial to drink water and other unsweetened fluids to help flush out the bacteria from the urinary tract. Therefore, this choice is incorrect.

A. "Prednisone can cause blood glucose levels to increase.” B. "Older adults are at risk for developing type 1 diabetes mellitus.” C. "Having COPD causes blood glucose levels to fluctuate.” D. "Albuterol treatments can cause blood glucose levels to decrease.”

Correct Answer is A

Explanation

Choice A rationale:

"Prednisone can cause blood glucose levels to increase." Rationale: This statement is accurate. Prednisone is a corticosteroid medication known to cause hyperglycemia (high blood glucose levels) as a side effect. It is important for the nurse to monitor the client's blood glucose levels while they are taking prednisone, especially if the client has preexisting diabetes or risk factors for diabetes.

Choice B rationale:

"Older adults are at risk for developing type 1 diabetes mellitus." Rationale: This statement is incorrect. Type 1 diabetes mellitus typically develops in childhood or early adulthood and is characterized by autoimmune destruction of the insulin-producing cells in the pancreas. Older adults are more at risk for developing type 2 diabetes, which is different from type 1 diabetes in terms of its etiology and pathophysiology.

Choice C rationale:

"Having COPD causes blood glucose levels to fluctuate." Rationale: This statement is not accurate. COPD (Chronic Obstructive Pulmonary Disease) primarily affects the respiratory system and does not directly cause blood glucose level fluctuations. Blood glucose levels can be affected indirectly in some cases due to factors like medications or stress associated with the illness, but it is not a direct result of COPD.

Choice D rationale:

"Albuterol treatments can cause blood glucose levels to decrease." Rationale: This statement is not a typical effect of albuterol treatments. Albuterol is a bronchodilator commonly used to treat respiratory conditions like COPD and asthma. It is not known to cause significant decreases in blood glucose levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily.The client asks why the nurse is checking his blood glucose level.Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

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?

A nurse is reinforcing teaching with a client who has an open leg wound and is experiencing difficulty healing.The nurse should encourage the client to increase which of the following nutrients in his diet?

A nurse is caring for an older adult client who wears hearing aids with detachable ear molds.Which of the following actions should the nurse take when caring for the hearing aids?

A nurse is assisting with the development of an education program for a group of older adults.Which of the following actions should the nurse take first?

A nurse is assisting with the discharge of an older adult client who has early onset dementia and lives with their adult child who works full time.Which of the following resources should the nurse recommend to the family to assist with the client's care?