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 B

Explanation

Choice A rationale:

This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.

Choice B rationale:

This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.

Choice C rationale:

This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.

Choice D rationale:

This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.

A. Use light restraints while the client is in bed. B. Place a lock at the top of doors leading outside. C. Encourage the client to nap during the day. D. Administer an antianxiety medication before bedtime.

Correct Answer is B

Explanation

Choice A rationale:

Using restraints can lead to injury and is generally a last resort.

Choice B rationale:

Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.

Choice C rationale:

Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.

Choice D rationale:

While medication can be helpful, non-pharmacological interventions should be tried first.

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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 collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination? .

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?.

Correct Answer is B

Explanation

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium? .

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique? .

A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?.

A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?.

A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at the highest risk for physical abuse? .

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

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.