The nurse continues to care for the client.

Exhibits

Complete the following sentence by using the lists of options.

The client is at greatest risk for
dropdown
due to
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Choices:

Self-harm: The client expresses suicidal ideation influenced by delusions, indicating a strong risk of acting on these impulses. In schizophrenia, command hallucinations are particularly dangerous when they involve instructions to harm oneself.
Command hallucinations: The client reports hearing voices directing them to act, which is a hallmark of command hallucinations. These are associated with a heightened risk of harm to self or others, especially when the client appears fearful or paranoid, as in this case.

Rationale for Incorrect Choices:

Palming medications: Although the client is suspicious and refuses medication (“I’m not letting you poison me”), there is no evidence yet of palming or hiding pills. The agitation could indicate refusal, but not covert medication avoidance.
Poor hygiene: While the client shows confusion regarding bathing and clothing, these are not the most immediate safety threats compared to suicide risk. Poor hygiene is a concern in schizophrenia but not the most critical issue at this time.
Impaired memory: Impaired memory is evident (e.g., forgetting routines), but this is not directly linked to a life-threatening risk. Memory issues can affect functioning but don’t explain the urgency of the client’s safety threat.
Distractibility: The client appears distracted at times (e.g., during dressing), but distractibility alone does not account for the risk of self-harm. It contributes to disorganization but is not the main safety concern.

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Correct Answer is C

Explanation

Rationale:

A. Select a vein on the back of the hand: Veins on the dorsum of the hand are often more fragile and prone to infiltration or rupture in older adults. Using a more proximal site, such as the forearm, is generally safer and more stable for IV therapy.

B. Clean the site using vigorous friction: Older adults often have thinner, more delicate skin that can tear easily. While proper antiseptic technique is important, vigorous friction can cause skin trauma and should be avoided during site preparation.

C. Use a 22-gauge catheter for insertion: A 22-gauge catheter is appropriate for older adults because it minimizes vein trauma while still allowing for adequate flow rates. This size is effective for most fluids and medications while reducing the risk of vessel damage.

D. Apply a tourniquet firmly above the insertion site: Applying a tourniquet too tightly can injure fragile veins or cause them to collapse. In older adults, using minimal pressure or alternative vein-dilation methods like warm compresses is often safer.

A. "Maintain the client in a supine position for 24 hours following surgery." B. "Expect the client to have a palpable distended bladder following surgery." C. "Report bleeding that saturates the client's dressing." D. "Ensure the client's urinary output is no less than 20 mL per hour."

Correct Answer is C

Explanation

Rationale:

A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.

B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.

C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.

D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.

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The nurse continues to care for the client. Exhibits Complete the following sentence by using the lists of options. The client is at greatest risk for dropdown due to dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Correct Answer is C

Explanation

The nurse reviews the Nurses' Notes from Day 1 at 1100.Exhibits Select the 4 tasks the nurse should plan to delegate to the assistive personnel (AP)

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A nurse is providing teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse Include in the teaching?

A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?

A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

A nurse is caring for a toddler in the outpatient setting. Exhibits Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developed dropdown due to dropdown.

The nurse continues to care for the client.

Exhibits

Complete the following sentence by using the lists of options.

The client is at greatest risk for
dropdown
due to
dropdown
.