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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

due to .
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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Related Questions

Correct Answer is C

Explanation

Rationale:

A. Take mineral oil at bedtime: Mineral oil is not recommended for long-term use because it can interfere with absorption of fat-soluble vitamins and may lead to aspiration pneumonia, especially in older adults. Safer stool softeners or laxatives should be used for opioid-induced constipation.

B. Decrease insoluble fiber intake: Insoluble fiber, such as wheat bran, helps bulk the stool and promote bowel movements. Reducing fiber intake can worsen constipation rather than relieve it, especially in clients taking opioids.

C. Increase exercise activity: Regular physical activity stimulates peristalsis and helps prevent constipation. Movement is a key non-pharmacologic strategy to counteract the slowed gastrointestinal motility caused by opioids.

D. Drink 1.5 L of fluids each day: Although hydration is important, adults typically require around 2 to 3 liters of fluid daily unless contraindicated. Limiting intake to 1.5 L may be insufficient to support normal bowel function and soften stool.

Correct Answer is ["A","B","C"]

Explanation

Rationale:

A. Maternal diabetes: Infants born to diabetic mothers are at increased risk for hypoglycemia due to elevated insulin levels stimulated by maternal hyperglycemia. After birth, the abrupt loss of maternal glucose can lead to a rapid drop in the infant’s blood sugar.

B. Prematurity: Premature infants have limited glycogen stores and immature metabolic systems, making them more susceptible to hypoglycemia. Their inability to effectively regulate glucose levels increases their risk after birth.

C. Hypothermia: Cold stress increases metabolic demands and glucose consumption. As the infant uses more energy to maintain body temperature, blood glucose levels can drop rapidly if not closely monitored and managed.

D. Thrombocytopenia: Low platelet counts may indicate other underlying conditions but are not directly associated with hypoglycemia. It is more relevant to clotting and bleeding risks rather than glucose regulation.

E. Anemia: Anemia affects oxygen-carrying capacity but does not have a direct link to blood glucose control. While it may indicate other health issues, it is not a recognized independent risk factor for neonatal hypoglycemia.

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