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if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.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 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. "We need to check the client's urine output every hour.” B. "Expect the stoma to appear pale until healing is complete.” C. "Expect the client's urine to contain clots for the first 24 hours.” D. "We will keep the client's fluid intake restricted until he is free of pain.”

Correct Answer is A

Explanation

The correct answer is A. "We need to check the client's urine output every hour."

Choice A rationale:

Monitoring urine output every hour is crucial for assessing kidney function and ensuring the urostomy is functioning properly, especially in the immediate postoperative period.

Choice B rationale:

A pale stoma is not an expected finding. A healthy stoma should be pink to red. A pale stoma could indicate inadequate blood supply and needs immediate evaluation.

Choice C rationale:

While some blood or small clots in the urine might be expected shortly after surgery, this is not a standard instruction to give. Any significant or persistent bleeding should be reported and assessed promptly.

Choice D rationale:

Restricting fluid intake is generally not recommended after surgery unless specifically ordered. Adequate hydration is important for recovery and maintaining urinary output.

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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 discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?

Correct Answer is A

Explanation

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.The nurse notes that the client's vagina and vulva are a purplish color.The nurse should document this finding as which of the following?

A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

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

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers.Which of the following foods should the nurse include?

A nurse is caring for a client who is to begin chemotherapy.The client asks the nurse about managing hair loss.Which of the following responses should the nurse make?

A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take?