The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

Exhibits

For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Administer acyclovir.

Administer lorazepam.

Initiate 1:1 supervision.

Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.

Answer and Explanation

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

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A rationale:

Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.

Choice B rationale:

Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.

Choice C rationale:

Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.

Choice D rationale:

While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.

A. "I'm using a syringe to obtain your blood, not a snake.”. B. "Your provider requires this blood specimen.”. C. "You must be mistaken. D. Snakes cannot be in the clinic.”.

Correct Answer is D

Explanation

(Null)

View Question and Answer

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The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?.

Correct Answer is C

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

Correct Answer is D

Explanation

A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep? .

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?.

A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?.

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?.

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) .

A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?.

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

Exhibits

For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.