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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.

A.

Administer acyclovir.

B.

Administer lorazepam.

C.

Initiate 1:1 supervision.

D.

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.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:

Checking blood pressure once a week is a good practice, especially for clients on medications that can affect blood pressure.

Choice B rationale:

Chewing sugar-free gum several times daily is not harmful and can help with dry mouth, a common side effect of haloperidol.

Choice C rationale:

Avoiding alcohol while taking haloperidol is recommended as alcohol can increase the side effects of the medication.

Choice D rationale:

Spending several hours a day outside gardening when it’s sunny can lead to a condition called photosensitivity, a side effect of haloperidol. The client should be advised to wear protective clothing and sunscreen when outside.

Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. People with bulimia nervosa often consume large amounts of food in a short period of time, known as binge eating.

Choice B rationale:

This statement is correct. Despite the binge-purge cycle, individuals with bulimia nervosa can maintain an average or ideal body weight, making the disorder less noticeable.

Choice C rationale:

This statement is incorrect. While self-induced vomiting is a common method of purging in bulimia nervosa, other methods such as excessive exercise, fasting, or misuse of laxatives, diuretics, or enemas can also be used.

Choice D rationale:

This statement is incorrect. While bulimia nervosa can lead to various health complications, it is not directly associated with the development of diabetes mellitus.

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