The nurse continues to care for the client.

Exhibits

Complete the following sentence by using the lists of options.

The client is at greatest risk for
dropdown
due to
dropdown
.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Autonomy: Autonomy involves respecting a client’s right to make their own healthcare decisions. While important, this scenario concerns unequal treatment rather than limiting the clients’ decision-making rights.

B. Justice: Justice refers to fairness and equity in the distribution of healthcare resources. Providing supplies to one client based on insurance status while denying them to another reflects unequal and unethical treatment, violating the principle of justice.

C. Beneficence: Beneficence means acting in the best interest of the client by promoting well-being. Although the insured client is benefitting, failing to support the uninsured client equally undermines the overall intent to do good for all clients.

D. Nonmaleficence: Nonmaleficence is the obligation to do no harm. While denying supplies could lead to harm, the primary ethical breach in this situation lies in the unfair distribution of care, which relates more directly to justice.

A. Pale and a 24-hr fluid deficit of 30 mL B. Temperature 38° C (100.4° F) and pulse rate 124/min C. Decreased appetite and irritability D. Sunken fontanels and dry mucous membranes

Correct Answer is D

Explanation

Rationale:

A. Pale and a 24-hr fluid deficit of 30 mL: Mild pallor and a small fluid deficit are not uncommon in early stages of illness and may not require immediate intervention. However, more serious signs of dehydration would take priority for reporting.

B. Temperature 38° C (100.4° F) and pulse rate 124/min: These are within expected limits for an infant with mild infection or fever. While they should be monitored, they are not urgent indicators of severe complications from gastroenteritis.

C. Decreased appetite and irritability: These are common symptoms in infants with viral illnesses, including gastroenteritis. Although they affect comfort and feeding, they are not necessarily indicators of serious fluid or electrolyte imbalance.

D. Sunken fontanels and dry mucous membranes: These are clinical signs of moderate to severe dehydration, which is a serious complication of gastroenteritis in infants. These findings must be reported promptly for urgent intervention to prevent further deterioration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse continues to care for the client. Exhibits Complete the following sentence by using the lists of options. The client is at greatest risk for dropdown due to dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

A nurse is providing medication teaching about disulfiram for a client who has alcohol use disorder. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is calculating the BMI of a client who has a weight of 75 kg (165.3 lb) and a height of 1.8 m (5 ft 9 in). Which of the following values should the nurse calculate as the client's BMI?

A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management measures should the nurse identify as a safe option for the client?

A nurse is caring for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to administer?

A nurse is caring for a client who has angina and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?

A nurse is caring for a client in an emergency department (ED).Exhibits Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client's condition is improving?

The nurse continues to care for the client.

Exhibits

Complete the following sentence by using the lists of options.

The client is at greatest risk for
dropdown
due to
dropdown
.