The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400.

Exhibits

Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)

Temperature

Hallucinations

Oxygen saturation

Heart rate

Orientation

Blood pressure

Answer and Explanation

Correct Answer : A,B,D,E,F

Choice A: Temperature
Reason: The client’s temperature decreased from 38.6°C (101.5°F) at 0200 and 0415 to 37.2°C (98.9°F) at 1400. This indicates a reduction in fever, which is a sign of improvement in the client’s condition.
Choice B: Hallucinations
Reason: Initially, the client was experiencing hallucinations, as evidenced by the statement about seeing someone in an empty chair. By 1400, no hallucinations were observed, indicating an improvement in the client’s mental status.
Choice C: Oxygen Saturation
Reason: The client’s oxygen saturation remained stable at 98% on room air throughout the observations. While this is within the normal range (95-100%), it does not indicate a change or improvement in the client’s condition.
Choice D: Heart Rate
Reason: The client’s heart rate decreased from 104/min at 0200 and 108/min at 0415 to 78/min at 1400. This reduction to within the normal range (60-100 beats per minute) indicates an improvement in the client’s condition.
Choice E: Orientation
Reason: Initially, the client was confused and disoriented. By 1400, the client was awake, oriented to person and place, and watching television, indicating an improvement in cognitive function.
Choice F: Blood Pressure
Reason: The client’s blood pressure decreased from 158/96 mm Hg at 0200 and 148/94 mm Hg at 0415 to 128/84 mm Hg at 1400. This reduction to within the normal range (90/60 mm Hg to 120/80 mm Hg) indicates an improvement in the client’s condition.

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Correct Answer is ["1.5"]

Explanation

Step 1: Determine the total dosage required.

375 mg

Step 2: Determine the dosage per tablet.

250 mg

Step 3: Calculate the number of tablets needed.

375 mg ÷ 250 mg = 1.5 tablets

The nurse should administer 1.5 tablets.

A. Repeat orientation questions until the client gives a correct response. B. Provide the client with a dark environment for sleeping. C. Make a personal introduction to the client at each interaction. D. Give the client a list of foods to choose from for dinner.

Correct Answer is C

Explanation

Choice A Reason:
Repeating orientation questions until the client gives a correct response is not an effective strategy for managing dementia. Clients with dementia often have memory impairments and may not be able to provide the correct response even after repeated questioning. This approach can lead to frustration and anxiety for the client. Instead, the nurse should use gentle reminders and cues to help orient the client without causing stress.

Choice B Reason:
Providing the client with a dark environment for sleeping is generally a good practice for promoting sleep hygiene. However, in the context of dementia care, it is not the most critical action. Clients with dementia may experience confusion and disorientation, especially in the dark. It is important to ensure that the environment is safe and that there is adequate lighting to prevent falls and injuries.

Choice C Reason:
Making a personal introduction to the client at each interaction is crucial in dementia care. Clients with dementia may have difficulty recognizing people, including caregivers. By introducing themselves each time, nurses can help reduce confusion and anxiety for the client. This practice also helps build trust and rapport, which are essential for effective care.

Choice D Reason:
Giving the client a list of foods to choose from for dinner can be beneficial in promoting autonomy and independence. However, clients with dementia may have difficulty making decisions and may become overwhelmed by too many choices. It is better to offer a limited number of options or to present the choices one at a time to make the decision-making process easier for the client.

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The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400. Exhibits Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer disulfiram 375 mg PO once daily. Available is disulfiram 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.5"]

Explanation

A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400.

Exhibits

Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)