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The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

Exhibits

For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

A.

Administer acyclovir.

B.

Administer lorazepam.

C.

Initiate 1:1 supervision.

D.

Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:

Teaching sessions right before bedtime may not be effective as older adults may be tired and less able to concentrate.

Choice B rationale:

Establishing long-term goals can be overwhelming for older adults. Short-term goals are more manageable and achievable.

Choice C rationale:

Long teaching sessions may lead to fatigue and decreased concentration. Short, frequent sessions are more effective.

Choice D rationale:

Using “I” statements rather than “you” statements can help create a more positive and collaborative learning environment.

Correct Answer is A

Explanation

Choice A rationale:

Administering lithium with meals can help reduce gastrointestinal upset, a common side effect of the medication.

Choice B rationale:

Lithium does not typically cause hypoglycemia. It primarily affects the nervous system and kidneys.

Choice C rationale:

There’s no need to decrease dietary potassium. Lithium can affect sodium levels, but not potassium.

Choice D rationale:

Increasing daily caloric intake is not necessary when taking lithium. The medication does not affect metabolism or caloric needs.

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