The nurse continues to care for the client.
Complete the following sentence by using the lists of options.
The client is at greatest risk for
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Instruct the client to have his testosterone checked in 1 week: Testosterone levels are typically monitored after several weeks of therapy, not within just one week. Early testing may not accurately reflect the medication's effectiveness or stability in the bloodstream.
B. Wear clean gloves to apply the gel: Gloves must be worn, but they should be disposable and protective not simply clean gloves. This prevents accidental transdermal absorption of testosterone by the nurse, which can have hormonal effects, especially in females.
C. Apply the gel to the client's genital region: Testosterone gel should not be applied to the genital area due to the risk of irritation and unpredictable absorption. Recommended sites include the shoulders, upper arms, or abdomen where the skin is intact and dry.
D. Advise the client to wait 1 hr before showering or swimming: The client should be instructed to wait at least 1 hour to allow for full absorption of the gel. Showering or swimming too soon can reduce the effectiveness of the medication.
Correct Answer is C
Explanation
Rationale:
A. Place a warm pack on the incisional area: Applying a warm pack immediately postoperatively can increase blood flow and risk bleeding or swelling at the surgical site. Cold packs are generally preferred in the immediate postoperative period to reduce inflammation.
B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated after hernia repair unless the client has a comorbid condition like heart or renal failure. Adequate hydration supports healing and normal bowel and urinary function.
C. Elevate the client's scrotum on a pillow: Elevating the scrotum helps reduce swelling and discomfort after hernia repair, especially if the inguinal area is involved. This intervention promotes venous return and prevents complications like hematoma formation.
D. Encourage the client to sit to void: Sitting to void is not routinely necessary after hernia repair unless the client has mobility issues. There’s no specific benefit to this position in a typical male postoperative client.
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