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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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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Free Nursing Study Resources

Correct Answer is ["B","D","E","F"]

Explanation

Choice A rationale:

Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.

Choice B rationale:

Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.

Choice C rationale:

Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.

Choice D rationale:

Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.

Choice E rationale:

Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.

Choice F rationale:

Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.

A. Decreased platelets. B. Increased erythrocyte sedimentation rate. C. Decreased hemoglobin. D. Increased iron level.

Correct Answer is B

Explanation

Choice A rationale:

Decreased platelets are not typically an indicator of infection. Platelet levels may decrease in conditions like thrombocytopenia, but they are not a specific indicator of infection.

Choice B rationale:

Increased erythrocyte sedimentation rate (ESR) is an indicator of infection. An elevated ESR is a nonspecific marker of inflammation in the body, which can be seen in response to infection, among other conditions.

Choice C rationale:

Decreased hemoglobin is not typically an indicator of infection. Hemoglobin levels may decrease in conditions like anemia, but they are not a specific indicator of infection.

Choice D rationale:

Increased iron levels are not typically an indicator of infection. Iron levels can vary for various reasons, but they are not a direct marker of infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["B","D","E","F"]

Explanation

A nurse is reinforcing teaching about laboratory testing with a client.Which of the following findings should the nurse include as an indicator of infection?

Correct Answer is B

Explanation

A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month-old infant. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder.Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with the care of a client who has pneumonia. Exhibits For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding.Which of the following findings should the nurse expect?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?