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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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 D
Explanation
Choice A rationale:
Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.
Choice B rationale:
A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.
Choice C rationale:
A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.
Choice D rationale:
Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.
Correct Answer is B
Explanation
Choice A rationale:
While vitamin D is essential for bone health and wound healing, it is not the primary nutrient to focus on in this case. Protein plays a crucial role in wound healing because it is necessary for tissue repair and the production of collagen, which is essential for wound closure.
Choice B rationale:
Increasing protein intake is the correct choice. Proteins are the building blocks of tissue repair and wound healing. Adequate protein intake is essential for promoting the healing of open wounds.
Choice C rationale:
Calcium is important for bone health but is not the primary nutrient to address in this situation. Calcium is not directly involved in wound healing processes.
Choice D rationale:
Fats are necessary for overall health, but they do not have a direct role in wound healing. Protein intake is more critical in this context to promote tissue repair and healing.
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