The nurse continues to care for the client.
Complete the following sentence by using the lists of options.
The client is at greatest risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for Correct Choices:
- Self-harm: The client expresses suicidal ideation influenced by delusions, indicating a strong risk of acting on these impulses. In schizophrenia, command hallucinations are particularly dangerous when they involve instructions to harm oneself.
- Command hallucinations: The client reports hearing voices directing them to act, which is a hallmark of command hallucinations. These are associated with a heightened risk of harm to self or others, especially when the client appears fearful or paranoid, as in this case.
Rationale for Incorrect Choices:
- Palming medications: Although the client is suspicious and refuses medication (“I’m not letting you poison me”), there is no evidence yet of palming or hiding pills. The agitation could indicate refusal, but not covert medication avoidance.
- Poor hygiene: While the client shows confusion regarding bathing and clothing, these are not the most immediate safety threats compared to suicide risk. Poor hygiene is a concern in schizophrenia but not the most critical issue at this time.
- Impaired memory: Impaired memory is evident (e.g., forgetting routines), but this is not directly linked to a life-threatening risk. Memory issues can affect functioning but don’t explain the urgency of the client’s safety threat.
- Distractibility: The client appears distracted at times (e.g., during dressing), but distractibility alone does not account for the risk of self-harm. It contributes to disorganization but is not the main safety concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. The nurse explained the risks and benefits of the surgery: Explaining the risks and benefits of a surgical procedure is the responsibility of the surgeon, not the nurse. The nurse may clarify or reinforce information but does not provide the primary explanation.
B. The nurse explained the surgical procedure in detail: Nurses can offer general clarification, but it is the surgeon’s legal and ethical duty to explain the procedure in detail, including alternatives, risks, and benefits, as part of obtaining informed consent.
C. The client knows they may no longer refuse the procedure: Clients have the legal right to refuse a procedure at any time, even after signing consent. Consent is not binding and must remain voluntary and revocable until the procedure begins.
D. The client agreed to the procedure voluntarily: Informed consent requires that the client makes the decision freely, without coercion. Observing the client voluntarily agree to the procedure meets this core legal and ethical requirement of informed consent.
Correct Answer is ["200"]
Explanation
Calculation:
Total volume = 100 mL.
- Convert the infusion time from minutes to hours.
Infusion time = 30 min / 60 min/hr
= 0.5 hr.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
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