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

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Correct Answer is A

Explanation

Rationale:

A. Ask an experienced nurse to assist with the procedure: Seeking guidance from an experienced nurse supports safe practice and skill development. It ensures the procedure is performed correctly while providing an opportunity for supervised learning, which is appropriate for a newly licensed nurse.

B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires the clinical judgment and skills of a registered nurse. It should not be delegated to assistive personnel who are not trained or licensed to perform such procedures.

C. Refuse to take the assignment: Refusing the assignment without attempting to seek help or learn is not a constructive or professional approach. Nurses are expected to seek support when performing unfamiliar but appropriate tasks within their role.

D. Identify that the task is in the scope of RN practice and perform the suctioning: While it is within the RN scope, performing a skill without training or supervision may compromise patient safety. Competence must be demonstrated or developed with supervision before performing independently.

A. "Rinse your mouth with an alcohol-based mouthwash." B. "Eat foods served at hot temperatures." C. "Use ice chips to numb your mouth." D. "Add salt to season foods.”

Correct Answer is C

Explanation

Rationale:

A. "Rinse your mouth with an alcohol-based mouthwash.": Alcohol-based mouthwashes can further irritate the mucous membranes, worsen oral discomfort, and dry the oral tissues, especially in clients with mucositis or candidiasis common in AIDS.

B. "Eat foods served at hot temperatures.": Hot foods can aggravate oral sores and cause more pain or tissue damage. Cool or room-temperature foods are typically better tolerated when the mouth is sore.

C. "Use ice chips to numb your mouth.": Ice chips can provide temporary relief by numbing oral tissues, reducing inflammation, and making eating more comfortable. This is a helpful, non-pharmacologic intervention for oral pain.

D. "Add salt to season foods.": Salt can irritate open or inflamed oral tissues and worsen the discomfort. Bland, soft foods without strong seasonings are usually better tolerated in cases of mouth soreness.

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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

A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has AIDS. The client states, "My mouth is sore when I eat." Which of the following instructions should the nurse provide?

Correct Answer is C

Explanation

A nurse is preparing to administer testosterone gel to a client who has hypogonadism. Which of the following actions should the nurse take?

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

The nurse continues to care for the client.Exhibits The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.

A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

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 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?

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
.