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:

Encouraging the client to attend a daily exercise program on the unit is beneficial for the client’s health, but it does not demonstrate the ethical principle of veracity, which involves truthfulness and honesty.

Choice B rationale:

Maintaining the client’s confidentiality about a substance use disorder is an important aspect of nursing care, but it demonstrates the ethical principle of confidentiality, not veracity.

Choice C rationale:

Reinforcing information on the potential adverse effects of a medication with the client is an example of veracity. The nurse is being truthful and transparent about the potential risks associated with the medication.

Choice D rationale:

Respecting the client’s right to refuse to attend a group therapy session demonstrates the ethical principle of autonomy, not veracity.

A. Document the client's behavior in the medical record every 1 hr B. Provide range-of-motion exercises to all extremities every 2 hr. C. Request the provider renew the prescription in 24 hr. D. Keep staff interactions with the client to a minimum.

Correct Answer is B

Explanation

Choice A rationale:

Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.

Choice B rationale:

Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.

Choice C rationale:

The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.

Choice D rationale:

Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.

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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 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?.

Correct Answer is C

Explanation

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?.

Correct Answer is B

Explanation

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?.

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?.

A nurse is caring for a client who has a new diagnosis of cancer. The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?.

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.

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?.

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?.

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.