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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 B

Explanation

Choice A rationale:

Hypomagnesemia is not a common finding in clients with bulimia nervosa.

Choice B rationale:

Hypokalemia is a common finding due to purging behaviors, such as self-induced vomiting or misuse of laxatives, which can lead to loss of potassium.

Choice C rationale:

Muscle wasting is more commonly associated with anorexia nervosa, not bulimia nervosa.

Choice D rationale:

Lanugo, or fine body hair, is also more commonly associated with anorexia nervosa, not bulimia nervosa.

Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. Opioid withdrawal typically results in tachycardia, not bradycardia.

Choice B rationale:

This statement is correct. Diarrhea is a common symptom of opioid withdrawal.

Choice C rationale:

This statement is incorrect. Opioid withdrawal often results in restlessness and agitation, not hypokinesis.

Choice D rationale:

This statement is incorrect. Opioid withdrawal typically results in dilated pupils, not meiosis.

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