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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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

Explanation

Choice A rationale:

An entry on a nursing blog, while potentially informative, does not provide the same level of evidence-based information as a peer-reviewed journal article. Blog posts may not undergo rigorous peer review and may lack the scientific rigor and credibility associated with peer-reviewed research. Therefore, choice A is not the best source for evidence-based information.

Choice B rationale:

Information from a wound care product vendor may be biased and influenced by commercial interests. Vendors often aim to promote their products, and the information they provide may not be impartial or based on rigorous scientific research. Therefore, choice B is not the best source for evidence-based information.

Choice C rationale:

A peer-reviewed journal article is considered one of the most reliable sources of evidence-based information in healthcare. Such articles undergo a thorough review process by experts in the field to ensure the accuracy, quality, and validity of the research findings. Peer-reviewed articles provide credible and up-to-date information based on scientific research and are widely recognized as a gold standard in evidence-based practice. Therefore, choice C is the correct answer as it offers the best evidence-based information.

Choice D rationale:

First-hand experience with wound care products, while valuable, may not necessarily provide the most comprehensive or up-to-date information. Personal experiences can vary, and healthcare practices evolve over time based on research and new evidence. Therefore, choice D is not the best source for evidence-based information.

A. "Has anyone in your family ever died by suicide?” B. "Can you tell me about the stresses in your life?” C. "Do you have a plan for harming yourself?” D. "Do you have someone to discuss your feelings with?”

Correct Answer is C

Explanation

Choice A rationale:

Inquiring about a family history of suicide is relevant but not the priority when a client is actively expressing suicidal ideations. Assessing the client's immediate risk and intent is more critical.

Choice B rationale:

Understanding the stresses in the client's life is important, but asking about a plan for self-harm takes precedence in assessing the client's immediate danger.

Choice C rationale:

This question directly addresses the client's intent and plan for self-harm. Identifying a plan is crucial in assessing the level of risk and determining the appropriate intervention.

Choice D rationale:

While having someone to discuss feelings with is important, it is not the primary concern when a client is expressing suicidal ideations. Assessing the client's immediate risk and plan for self-harm should come first.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff.Which of the following sources should the nurse identify as providing the best evidence-based information?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is expressing suicidal ideations.Which of the following questions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has heart failure.The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min.Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.Which of the following interventions should the nurse plan to include?

A nurse is caring for an adolescent who states, "I failed my math exam because the teacher doesn't like athletes." The nurse should identify that the adolescent is using which of the following defense mechanisms?

A nurse is reviewing information about ethical client care with a newly licensed nurse.Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath.Which of the following actions should the nurse take first?

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?