The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.
For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
Administer acyclovir.
Administer lorazepam.
Initiate 1:1 supervision.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
| Potential Provider Prescription | Expected or Unexpected? | Explanation |
|---|---|---|
| Administer acyclovir. | Unexpected | Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause. |
| Administer lorazepam. | Expected | Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention. |
| Initiate 1:1 supervision. | Expected | The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety. |
| Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion. | Expected | The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration. |
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "I anticipate that my child will feel some self-blame."
Choice A rationale: Recognizing that the adolescent may experience self-blame demonstrates understanding and empathy from the guardian. This statement suggests that the guardian is aware of potential emotional challenges the adolescent might face and can provide appropriate support.
Choice B rationale: While monitoring relationships may come from a place of concern, overly controlling behavior could potentially harm the adolescent's social development and trust in their support system.
Choice C rationale: Encouraging the adolescent to focus solely on the future might dismiss their current emotional state and the importance of processing their feelings. A positive support system should provide space for the adolescent to work through their emotions.
Choice D rationale: Encouraging the adolescent to think about what they did that allowed the event to happen can promote feelings of guilt and self-blame. This approach is not supportive and could exacerbate the adolescent's trauma.
Correct Answer is C
Explanation
Choice A rationale:
Excessive anxiety is not typically associated with antisocial personality disorder. It is more commonly seen in anxiety disorders.
Choice B rationale:
Withdrawn behaviors are more commonly associated with disorders such as depression or social anxiety disorder, not antisocial personality disorder.
Choice C rationale:
Exploiting others is a common characteristic of antisocial personality disorder. Individuals with this disorder often manipulate or deceive others for personal gain.
Choice D rationale:
Blunted affect, or reduced emotional expression, is not typically associated with antisocial personality disorder. It is more commonly seen in disorders such as schizophrenia.
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