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
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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Restlessness is a common indicator of unrelieved pain in a client. It suggests that the client is uncomfortable and experiencing discomfort, which could be due to inadequate pain relief. Restlessness may manifest as frequent shifting, fidgeting, and an inability to find a comfortable position. Therefore, choice A is the correct answer as it is a reliable indicator of unrelieved pain.
Choice B rationale:
Urinary retention is not typically associated with unrelieved pain in a client with a spinal epidural for a herniated disc. Urinary retention may result from the effects of the epidural anesthesia itself but is not a specific indicator of unrelieved pain. Therefore, choice B is not the correct answer.
Choice C rationale:
Constipation is not a direct indicator of unrelieved pain related to a spinal epidural. Constipation can occur for various reasons, including medications, decreased mobility, and dietary factors. While pain may contribute to constipation indirectly, it is not a reliable and specific sign of unrelieved pain in this context. Therefore, choice C is not the correct answer.
Choice D rationale:
Difficulty swallowing is not typically associated with unrelieved pain related to a spinal epidural. It may be related to other factors, such as muscle weakness or neurological issues, but it is not a specific indicator of unrelieved pain in this situation. Therefore, choice D is not the correct answer.
Correct Answer is B
Explanation
Choice A rationale:
Placing a padded tongue blade in the child's mouth is not recommended during a tonic-clonic seizure. This action can cause injury to the child's mouth or teeth and does not help manage the seizure itself.
Choice C rationale:
Turning the child onto their back is generally the correct action to take during a seizure to ensure an open airway. However, this should be done gently and after ensuring the child's safety. Placing a pillow under the head is also important to prevent head injury during the seizure.
Choice D rationale:
Restraining the child's upper extremities is not recommended during a tonic-clonic seizure. It can lead to injury for both the child and the healthcare provider and is not an effective way to manage the seizure. The priority is to ensure the child's safety and protect them from harm.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.