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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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

Explanation

Choice A rationale:

"Obtain a prescription for pramipexole." Rationale: This statement is not appropriate for a pregnant client experiencing trouble sleeping. Pramipexole is a medication used to treat restless legs syndrome and Parkinson's disease. It is not typically prescribed for sleep disturbances during pregnancy.

Choice B rationale:

"Lie on your left side with your top leg forward." Rationale: This is the correct instruction. The recommended sleeping position during pregnancy is lying on the left side with the top leg forward. This position can help improve blood flow to the uterus and relieve pressure on major blood vessels, promoting better sleep.

Choice C rationale:

"Use a transcutaneous electrical nerve stimulator." Rationale: Using a transcutaneous electrical nerve stimulator (TENS) is not a standard intervention for pregnancy-related sleep problems. TENS units are typically used for pain management and are not indicated for sleep disturbances.

Choice D rationale:

"Soak in a bathtub of hot water each night." Rationale: This recommendation is not appropriate during pregnancy. Soaking in hot water for extended periods can raise the body's core temperature, which is not recommended during pregnancy as it may pose a risk to the developing fetus. Pregnant individuals should avoid hot tubs, saunas, and prolonged exposure to hot water.

A. Thick, white vaginal discharge. B. Hard, painless chancre. C. Feeling of pelvic heaviness. D. Frothy, malodorous discharge.

Correct Answer is A

Explanation

Choice A rationale:

Thick, white vaginal discharge is a common symptom of candidiasis, which is a fungal infection caused by Candida species. It is a characteristic finding in this condition.

Choice B rationale:

A hard, painless chancre is associated with syphilis, not candidiasis. This finding is not related to candidiasis.

Choice C rationale:

A feeling of pelvic heaviness is not a typical symptom of candidiasis. It may be associated with other gynecological conditions but is not specific to candidiasis.

Choice D rationale:

Frothy, malodorous discharge is characteristic of trichomoniasis, another type of vaginal infection caused by Trichomonas vaginalis. It is not a typical finding in candidiasis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping.Which of the following instructions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to undergo an amniocentesis.Which of the following information should the nurse include in the instructions?

A nurse is obtaining an oxygen saturation on a client.Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is implementing a bladder training program for a client who had a stroke.Which of the following interventions should the nurse take first?

A nurse is receiving change-of-shift report on four clients.Which of the following clients should the nurse plan to see first?

A nurse is collecting data on a client who has a heart rate of 44/min.Which of the following findings should the nurse expect?

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?