The nurse continues caring for the client.
Complete the following sentence by using the lists of options.
The nurse should
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for correct choice:
- Clarify the antibiotic prescription with the provider: The client has a known penicillin allergy, and ceftriaxone is a cephalosporin, which may cross-react with penicillin. The nurse should clarify this prescription to prevent a potential allergic reaction.
- Penicillin allergy: Due to the client's penicillin allergy, it’s essential to ensure that no antibiotics containing penicillin or related compounds are administered. Ceftriaxone should be verified with the provider to avoid causing an allergic reaction.
Rationale for incorrect choices:
- Perform medication reconciliation: While important, medication reconciliation is not as urgent as clarifying the antibiotic prescription to avoid a potential allergic reaction to ceftriaxone.
- Request a prescription for doxycycline: Doxycycline is not needed in this situation, as the prescribed antibiotics are appropriate for treating common STIs following sexual assault. The client is also allergic to doxycycline.
- Potential HIV exposure: HIV post-exposure prophylaxis (PEP) should be considered, but the priority here is to clarify the antibiotics. PEP can be addressed later with informed consent and appropriate protocols.
- Need for prophylaxis for human papillomavirus (HPV): HPV prophylaxis is not part of standard post-sexual assault care. Focus should be on preventing STIs, pregnancy, and HIV rather than HPV at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Schedule the client for a morning group fitness class at the facility: Regular morning exercise promotes healthy sleep patterns by helping regulate the body's circadian rhythm. Engaging in physical activity early in the day can reduce restlessness at night.
B. Limit the client to no more than four caffeinated beverages a day: While caffeine should be limited, the most effective approach is to avoid caffeine entirely in the afternoon and evening to prevent sleep disruption, rather than just limiting it to four beverages a day.
C. Walk around the hallway with the client an hour before bedtime: Although light physical activity can promote sleep, intense exercise or walking too close to bedtime can sometimes increase alertness and make it harder for the client to fall asleep.
D. Allow the client several hours in the afternoon to take a nap: Long naps, especially in the afternoon, can disrupt the client's sleep cycle and make it more difficult for them to fall asleep at night. Limiting naps during the day is typically more helpful.
Correct Answer is B
Explanation
A. The client is experiencing anisognosia: Anisognosia, a lack of awareness of one's own illness, is common in various psychiatric disorders, particularly in psychotic disorders like schizophrenia. While it is concerning, it does not typically require immediate reporting.
B. The client is experiencing command hallucinations: Command hallucinations, where the client hears voices telling them to take harmful actions, pose a direct safety risk. These should be immediately reported to the provider for further evaluation and intervention.
C. The client is exhibiting concrete thinking: Concrete thinking is common in individuals with certain psychiatric conditions, such as schizophrenia or intellectual disabilities. While it limits abstract thought, it is not an immediate cause for alarm.
D. The client is exhibiting a blunted affect: A blunted affect, or reduced emotional expression, is a common symptom in various mental health disorders. It is important for diagnosis and treatment planning but is not an immediate emergency or urgent situation.
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