The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.
Choice B rationale:
Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.
Choice C rationale:
Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.
Choice D rationale:
Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.
Correct Answer is A
Explanation
Choice A rationale:
Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.
Choice B rationale:
Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.
Choice C rationale:
Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.
Choice D rationale:
Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.
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