Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

The patient frequently uses an alcohol-based sanitizer for hand hygiene.

The patient takes acetaminophen 1000 mg every 4 hours around the clock.

The patient takes alprazolam 0.25 mg every 8 hours.

The patient rinses with a fluoride mouthwash after brushing the teeth.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.

Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.

Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 8 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.

Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.

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Correct Answer is A

Explanation

Choice A reason: This is correct. Unilateral neglect is a condition where the patient fails to attend to or respond to stimuli on the opposite side of the brain lesion. It can affect the patient's perception, attention, memory, and motor function. It can also impair the patient's safety, self-care, and quality of life. The patient may not recognize the existence of the paralyzed limbs, ignore them, or deny their ownership.

Choice B reason: This is incorrect. Ineffective denial is a condition where the patient consciously or unconsciously refuses to acknowledge the reality of a situation that is too threatening or overwhelming. It can interfere with the patient's coping and adaptation. The patient may reject the diagnosis, prognosis, or treatment of the condition. However, this is not the case for the patient with unilateral neglect, who is not aware of the paralysis, rather than refusing to accept it.

Choice C reason: This is incorrect. Deficient knowledge is a condition where the patient lacks or misinterprets information about a topic related to health or illness. It can affect the patient's decision-making, compliance, and outcomes. The patient may have inaccurate or incomplete understanding of the causes, consequences, or management of the condition. However, this is not the main problem for the patient with unilateral neglect, who is not able to process or attend to the information, rather than lacking it.

Choice D reason: This is incorrect. Noncompliance is a condition where the patient does not or is unable to follow the prescribed or agreed-upon plan of care. It can result from various factors, such as lack of motivation, resources, support, or understanding. The patient may not adhere to the recommendations, instructions, or goals of the treatment. However, this is not the primary issue for the patient with unilateral neglect, who is not capable of performing the tasks, rather than unwilling to do so.

A. Utilize a no-rinse shampoo cap. B. Use a handheld shower sprayer. C. Have the patient lean over the wash basin. D. Have the patient lean back into the sink.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because utilizing a no-rinse shampoo cap is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A no-rinse shampoo cap is a disposable cap that contains a pre-moistened shampoo and conditioner. It can be heated in a microwave and applied to the patient's head without the need for water or rinsing. It can clean and condition the patient's hair without causing any discomfort or movement of the affected shoulder.

Choice B reason: This is an incorrect choice because using a handheld shower sprayer is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A handheld shower sprayer is a device that attaches to a faucet and allows the user to direct the water flow. It can be difficult and painful for the patient to use or hold the sprayer with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice C reason: This is an incorrect choice because having the patient lean over the wash basin is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A wash basin is a bowl or sink that contains water and soap for washing. It can be uncomfortable and risky for the patient to lean over the basin with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice D reason: This is an incorrect choice because having the patient lean back into the sink is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A sink is a basin with a faucet that provides water for washing. It can be uncomfortable and risky for the patient to lean back into the sink with the affected shoulder, and it can also wet the surgical dressing or incision site.

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Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

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