The nurse continues to assist in the care of the client.

2030: Medication Administration Record.

Day 5, 0700: Ziprasidone 20 mg IM left deltoid muscle. Paliperidone 6 mg PO.

Nurses' Notes.

2015: 2030: Client appears disheveled with matted hair and stained clothing. Attempting to get out of handcuffs. The client states, "I have to. get out of here. I hear the helicopters. They are coming to get me!” Client able to state name, but not date. They believe they are in. a laboratory, run by the doctors who have been prescribing their medications.

When asked about their medical history, they reply, "My name is Jamie, and you are the devil.”

2145: Reviewed police report: Client found attempting to break through a window at the clinic downtown. When approached,. client yelled and tried to hit the officer with the stick they were using. "Get away, I have to get the notes, they are trying to. poison me.” Client appears to be responding to internal stimuli but is less outwardly agitated.

Changed into hospital scrubs with encouragement.

Handcuffs removed by police and 1:1 sitter at. The nurse is collecting data from the client 5 days after admission.

For each finding, click to specify whether the finding indicates the client's condition has improved or declined.

Response to other clients

Sleep patterns

Hygiene patterns

Interaction with the nurse

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Here are some possible answers: Response to other clients: This finding could indicate that the client’s condition has improved if they are more cooperative and respectful of others, or that it has declined if they are more hostile and paranoid of others. Sleep patterns: This finding could indicate that the client’s condition has improved if they are sleeping more regularly and peacefully, or that it has declined if they are sleeping less or having nightmares.

Hygiene patterns: This finding could indicate that the client’s condition has improved if they are taking care of their personal hygiene and appearance, or that it has declined if they are neglecting or refusing to do so. Interaction with the nurse: This finding could indicate that the client’s condition has improved if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale:

Hypercalcemia. Hypercalcemia refers to an elevated level of calcium in the blood. It is not typically a concern in a newborn, and monitoring for hypercalcemia is not necessary in this context. The infant's weight and maternal diabetes are more relevant factors to consider.

Choice B rationale:

Hypobilirubinemia. Hypobilirubinemia implies a low level of bilirubin in the blood, which is not a common concern in newborns, especially in the context of a newborn's weight and maternal diabetes. Monitoring for hyperbilirubinemia, which can lead to jaundice, would be more appropriate.

Choice C rationale:

Hypoglycemia. Hypoglycemia, or low blood sugar, is a significant concern in newborns of diabetic mothers. Newborns born to diabetic mothers are at increased risk of hypoglycemia due to the abrupt cessation of the continuous glucose supply from the mother's bloodstream after birth. Monitoring the newborn's blood glucose levels is crucial in this case.

Choice D rationale:

Decreased RBC. Monitoring for decreased red blood cell (RBC) counts is not typically a primary concern in a newborn, especially one born to a diabetic mother. Hypoglycemia, which can be a result of maternal diabetes, poses a more immediate and significant threat to the newborn's well-being.

A. Airborne. B. Protective. C. Droplet. D. Contact.

Correct Answer is A

Explanation

Choice A rationale:

Airborne precautions should be initiated for clients with tuberculosis (TB) who have a productive cough. TB is transmitted through the airborne route when an infected individual coughs, sneezes, or talks, releasing infectious droplets into the air. Airborne precautions include the use of negative-pressure isolation rooms and N95 respirators for healthcare workers to prevent the spread of TB.

Choice B rationale:

Protective precautions are not typically used for clients with TB. Protective precautions are more commonly employed for clients with compromised immune systems to protect them from infection.

Choice C rationale:

Droplet precautions are not sufficient for clients with TB because TB is primarily transmitted via airborne particles, not droplets. Droplet precautions are used for diseases like influenza or meningitis, which are transmitted through larger respiratory droplets.

Choice D rationale:

Contact precautions are not appropriate for clients with TB because TB is primarily transmitted through the airborne route. Contact precautions are typically used for diseases that are transmitted through direct contact with the client or contaminated surfaces.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus.For which of the following data should the nurse monitor?

Correct Answer is C

Explanation

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough.Which type of isolation precautions should the nurse initiate for the client?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a client who has botulism poisoning.Which of the following interventions should the nurse include in the plan?

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.Which of the following actions should the nurse take?

A nurse is assisting with the care of a client. Exhibits Data Collection Findings. For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

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

A nurse is reinforcing discharge teaching to a client following arthroscopic (joint) surgery.To prevent postoperative complications which of the following actions should be reinforced during the teaching of Continuous passive motion (CPM)?

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

A nurse is assisting with the discharge of an older adult client who has early onset dementia and lives with their adult child who works full time.Which of the following resources should the nurse recommend to the family to assist with the client's care?