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.

Administer acyclovir.

Administer lorazepam.

Initiate 1:1 supervision.

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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:

Attending a cognitive behavioral therapy class does not require informed consent as it is a non-invasive form of treatment.

Choice B rationale:

Informed consent is necessary when taking an experimental medication to ensure the client understands the potential risks and benefits.

Choice C rationale:

Light therapy is a non-invasive treatment and does not typically require informed consent.

Choice D rationale:

Participating in a group exercise program is a non-invasive form of treatment and does not require informed consent.

A. Absence of seizures B. Reduction in hand tremors. C. Decreased hallucinations. D. Improved mood.

Correct Answer is D

Explanation

Choice A rationale:

Absence of seizures is not an expected outcome of fluoxetine therapy. Fluoxetine is an antidepressant, not an anticonvulsant.

Choice B rationale:

Reduction in hand tremors is not an expected outcome of fluoxetine therapy. Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks.

Choice C rationale:

Decreased hallucinations is not an expected outcome of fluoxetine therapy. Fluoxetine is not typically used to treat conditions that cause hallucinations.

Choice D rationale:

Improved mood is an expected outcome of fluoxetine therapy. As an antidepressant, fluoxetine works by balancing chemicals in the brain that affect mood and emotions.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?.

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?.

Correct Answer is D

Explanation

A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep? .

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?.

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.) .

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first? .

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.