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 D
Explanation
Choice A rationale:
Ringing in the ears is not a common side effect of haloperidol.
Choice B rationale:
A metallic taste is not typically associated with haloperidol use.
Choice C rationale:
Urinary incontinence is not a known side effect of haloperidol.
Choice D rationale:
Haloperidol can cause photosensitivity, making the skin more sensitive to the sun.
Correct Answer is A
Explanation
Choice A rationale:
Making a personal introduction to the client at each interaction is a recommended approach for clients with dementia. It helps to orient the client and establish a connection, which can reduce confusion and anxiety.
Choice B rationale:
Giving a client with dementia a list of foods to choose from for dinner may be overwhelming due to impaired decision-making abilities.
Choice C rationale:
Choice D rationale:
Providing a dark environment for sleeping can be disorienting for a client with dementia. A low level of light can help the client maintain orientation to their surroundings.
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