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 B
Explanation
Rationale:
A. Troponin level: Troponin is a cardiac biomarker used to detect myocardial injury or infarction. It is not an indicator of nutritional status and does not reflect protein levels or nutrient balance.
B. Serum albumin: Albumin is a plasma protein synthesized in the liver and commonly used as a marker of long-term nutritional status. Low levels may suggest protein-energy malnutrition or chronic illness affecting nutrient absorption or intake.
C. Erythrocyte sedimentation rate: ESR is a nonspecific marker of inflammation or infection. While chronic disease can indirectly affect nutrition, ESR does not directly assess nutrient levels or dietary sufficiency.
D. Serum sodium: Sodium levels reflect fluid balance and electrolyte status but are not indicators of nutritional status. They may be influenced by hydration, renal function, or hormonal imbalances, not by dietary protein intake.
Correct Answer is ["A","B","E"]
Explanation
Rationale:
A. Administer Ibuprofen 200 mg PO: The child reports a pain score of 5/10 and is requesting pain medication. The provider has prescribed ibuprofen PRN for this level of pain. Prompt administration supports comfort and reduces inflammation associated with fracture and swelling.
B. Elevate the affected forearm with pillows: Elevation helps reduce edema by promoting venous return and lymphatic drainage. Given the child's worsening edema in the forearm and fingers, this is a priority to minimize complications like compartment syndrome.
C. Place a nonadherent dressing on the right knee abrasion: Although dressing the abrasion is a reasonable intervention, it is not a priority at this stage. The abrasion is not actively bleeding or infected, so attention should remain on managing neurovascular risk and pain.
D. Review cast care instructions with the child's parents: This is an important educational step, but it is not a current priority since the cast has not yet been applied. Priority actions should focus on pain, swelling, and circulation while awaiting casting.
E. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.
F. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.
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