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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Offering toileting opportunities every 1 to 2 hours is a valid intervention in a bladder training program. However, it should not be the first action. Before establishing a toileting schedule, the nurse should assess the client's current voiding patterns to determine the most appropriate schedule based on the client's needs.

Choice B rationale:

Assisting the client with relaxation techniques can be beneficial in managing urinary incontinence or frequency, but it should not be the first action. Understanding the client's voiding pattern and any factors contributing to their urinary issues is essential before implementing relaxation techniques.

Choice C rationale:

Determining the client's pattern for voiding is the first step in developing a tailored bladder training program. This assessment helps identify the client's specific needs and enables the nurse to create a personalized plan that addresses their issues effectively.

Choice D rationale:

Discouraging intake of carbonated beverages is a valid intervention in managing urinary incontinence or frequency, but it should not be the first action. It's important to assess the client's individual habits and patterns before making dietary recommendations.

A. Writing a client's diagnosis on the message board in the client's room. B. Discarding worksheets containing client information in a wastebasket. C. Giving change-of-shift report to a nurse outside the client's room. D. Discussing a client's prognosis with an assistive personnel who is caring for the client.

Correct Answer is C

Explanation

Choice A rationale: Writing a client's diagnosis on the message board in the client's room can expose sensitive information to anyone who enters the room, which compromises client confidentiality.

Choice B rationale: Discarding worksheets containing client information in a wastebasket is not secure and can lead to unauthorized access to confidential information.

Choice C rationale: Giving change-of-shift report to a nurse outside the client's room protects client confidentiality by ensuring that sensitive information is shared only with authorized personnel in a private setting.

Choice D rationale: While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

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?

Correct Answer is C

Explanation

A nurse is caring for a client who has hypoglycemia.The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

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 collecting data from a client who is 2 days postpartum.The client tells the nurse she cannot afford to pay for baby formula.The nurse should refer the client to which of the following members of the interprofessional team?

A nurse is assisting with the care of a client on an orthopedic unit. Exhibits Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown.

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops.Which of the following statements indicates an understanding of the teaching?

A nurse is preparing a client's body for a postmortem family viewing. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis.Which of the following information should the nurse include in the teaching?

A nurse is collecting data from a client who has placenta previa.Which of the following findings should the nurse expect?