🔷 The client is at highest risk for self-harm because the voices are telling them they are worthless and need to be “gone forever.”

🔷 These are command hallucinations, which are especially dangerous because the hallucinated voices are directing the client toward suicidal behavior.

🔷 Although the client denied suicidal thoughts on admission, the new statement on Day 3 shows an acute change and a direct safety concern.

🔷 The client also refused prescribed aripiprazole, which can worsen psychosis and increase the risk that hallucinations will intensify.

🔷 The priority nursing concern is immediate safety, close observation, suicide precautions, and rapid provider notification.

🔷 Escherichia coli is commonly spread through the fecal-oral route, especially when hand hygiene is poor after toileting or contact with contaminated surfaces.

🔷 Providing staff with alcohol-based hand gel improves access to hand hygiene and helps reduce transmission between residents.

🔷 In long-term care facilities, frequent hand hygiene is essential because residents often need assistance with toileting, bathing, feeding, and personal care.

🔷 Alcohol-based hand rub is appropriate when hands are not visibly soiled and can quickly reduce many microorganisms on the hands.

🔷 Staff should still use soap and water when hands are visibly dirty or after contact with stool because physical removal of contamination is important.

Administer prophylactic antiviral medication to the residents.

🔷E. coli is a bacterium, not a virus, so antiviral medication would not prevent or control its spread.

🔷Prophylactic antivirals are used for selected viral infections, not for bacterial gastrointestinal organisms.

Direct staff to rinse their hands for 10 seconds after washing with soap.

🔷Proper handwashing requires enough time for friction, soap, and rinsing to remove organisms effectively.

🔷A brief 10-second rinse after washing is not the key infection-control measure and may be inadequate if handwashing technique is poor.

Instruct staff to use airborne precautions.

🔷Airborne precautions are used for infections spread by tiny airborne particles, such as tuberculosis, measles, or varicella.

🔷E. coli is not spread through the airborne route, so airborne precautions are not indicated.

🔷 Reye syndrome is a rare but serious condition associated with giving aspirin to children who have viral illnesses such as influenza or varicella.

🔷 The toddler had confirmed Influenza A, and the parents report alternating aspirin and acetaminophen during the illness.

🔷 The new findings of persistent vomiting, lethargy, difficult arousal, and no urine output are concerning for acute deterioration and possible neurologic involvement.

🔷 Reye syndrome can cause acute encephalopathy and liver dysfunction, making early recognition critical.

🔷 Children with viral infections should receive safer antipyretics as prescribed, and aspirin should be avoided unless specifically ordered for a condition such as Kawasaki disease.

🔷 The nurse should follow the PASS technique when using a fire extinguisher: Pull, Aim, Squeeze, Sweep.

🔷 The first step is to pull the pin, which breaks the tamper seal and allows the extinguisher to discharge.

🔷 After pulling the pin, the nurse should aim the nozzle at the base of the fire, not the top of the flames.

🔷 The extinguisher should then be squeezed and swept side to side across the base of the fire.

🔷 This action is appropriate after activating the alarm and ensuring the fire is small enough to attempt extinguishing safely.

Aim the extinguisher's hose at the top of the flames.

🔷The extinguisher should be aimed at the base of the fire, where the fuel source is located.

🔷Aiming at the top of the flames does not effectively interrupt the fire source.

Use an up-and-down vertical motion to extinguish the fire.

🔷The correct motion is to sweep the extinguisher side to side across the base of the fire.

🔷An up-and-down motion may miss the fuel source and allow the fire to continue spreading.

Use a Class B fire extinguisher.

🔷A Class B extinguisher is used for flammable liquids, such as gasoline or oil.

🔷Smoke from an electrical outlet indicates an electrical fire, which requires a Class C or multipurpose extinguisher.

🔷 Citalopram is a selective serotonin reuptake inhibitor that increases serotonin availability in the central nervous system.

🔷 St. John’s Wort also has serotonergic effects and can increase serotonin activity when taken with antidepressants.

🔷 Taking both together increases the risk for serotonin syndrome, a potentially life-threatening condition caused by excessive serotonin.

🔷 Early findings can include restlessness, agitation, increased heart rate, elevated blood pressure, sweating, tremor, diarrhea, fever, and confusion.

🔷 The nurse should teach the client to avoid herbal supplements unless approved by the provider because “natural” products can still cause serious drug interactions.

🔷 A speech therapist is the appropriate referral for a client reporting difficulty swallowing, also known as dysphagia.

🔷 Speech therapists are trained to evaluate swallowing function, oral-motor control, gag response, and risk for aspiration.

🔷 Dysphagia can cause food, fluids, or saliva to enter the airway, increasing the risk for aspiration pneumonia.

🔷 The speech therapist may recommend thickened liquids, modified food textures, positioning strategies, and swallowing exercises.

🔷 This referral is important because safe swallowing protects the client’s airway, nutrition, hydration, and overall safety.

Respiratory therapist.

🔷A respiratory therapist helps manage oxygen therapy, breathing treatments, ventilators, and airway clearance.

🔷This client’s main issue is swallowing safety, so a speech therapist is the priority referral.

Occupational therapist.

🔷An occupational therapist helps clients improve activities of daily living, adaptive equipment use, and functional independence.

🔷Dysphagia management is more specifically handled by a speech therapist.

Pharmacist.

🔷A pharmacist can review medications that may affect swallowing or cause dry mouth.

🔷However, the direct referral for evaluation and treatment of swallowing difficulty is speech therapy.

🔶 Ferrous sulfate is best absorbed when taken between meals because food can decrease iron absorption.

🔶 Iron absorption is improved in an acidic environment, so taking it with vitamin C, such as orange juice, can increase effectiveness.

🔶 During pregnancy, iron supports increased maternal blood volume and helps prevent or treat iron-deficiency anemia.

🔶 The client should expect possible dark green or black stools, constipation, nausea, or mild stomach upset.

🔶 The nurse should teach the client to avoid taking iron with milk, calcium supplements, antacids, tea, or coffee because these can reduce absorption.

“I should take this medication with milk.”

🔶 Milk contains calcium, which binds with iron and decreases absorption.

🔶 The client should separate iron from dairy products for better therapeutic effect.

“I might have loose, yellow stools while taking this medication.”

🔶 Ferrous sulfate commonly causes dark stools, not yellow stools.

🔶 It is more likely to cause constipation than loose stools.

“I can take this medication with caffeinated beverages.”

🔶 Caffeinated beverages, especially tea and coffee, can reduce iron absorption.

🔶 The client should take iron with water or vitamin C-rich juice instead.

💎 Obtaining a blood glucose level is an appropriate task to delegate to an assistive personnel if the AP has been trained and deemed competent.

💎 This task is routine, standardized, and involves collecting objective data using a glucometer.

💎 The nurse remains responsible for interpreting the glucose result and deciding whether insulin, food, or provider notification is needed.

💎 Delegation is appropriate when the task does not require nursing judgment, teaching, assessment, or evaluation.

💎 In diabetes care, the AP may collect the value, but the nurse must use clinical judgment to manage the client’s condition safely.

Interpret the need to administer insulin.

💎Determining whether insulin is needed requires nursing judgment and interpretation of blood glucose results.

💎This responsibility cannot be delegated to assistive personnel.

Provide education on carbohydrate counting.

💎Teaching carbohydrate counting requires nursing knowledge, assessment of understanding, and individualized education.

💎This is outside the AP’s scope of practice.

Instruct the client on the use of a glucometer.

💎Teaching a client how to use a glucometer requires instruction, return demonstration, and evaluation.

💎The nurse must perform this teaching rather than delegating it to an AP.

🟢 A blood pressure of 144/92 mm Hg is elevated and requires nursing follow-up.

🟢 This reading falls within the hypertensive range and should be reassessed using correct cuff size, proper positioning, and adequate rest.

🟢 Persistent hypertension increases the risk for stroke, myocardial infarction, kidney disease, heart failure, and vascular damage.

🟢 The nurse should assess contributing factors such as pain, anxiety, recent activity, caffeine intake, medication use, or missed antihypertensive therapy.

🟢 Follow-up is needed because early identification and management of hypertension helps prevent long-term cardiovascular complications.

Oxygen saturation 96%.

🟢An oxygen saturation of 96% is generally within the expected range for most stable clients.

🟢It does not require follow-up unless the client has respiratory symptoms or a condition requiring a higher baseline saturation.

Temperature 37.7° C (100° F).

🟢A temperature of 37.7° C is a low-grade elevation.

🟢It should be monitored, but it is less urgent than a hypertensive blood pressure reading.

Respiratory rate 12/min.

🟢A respiratory rate of 12/min is within the expected adult range.

🟢It does not require follow-up unless accompanied by distress, sedation, altered mental status, or abnormal oxygenation.

🟣 Dependent personality disorder is characterized by an excessive need to be cared for and difficulty functioning independently.

🟣 Clients often appear submissive, clingy, and overly reliant on others for decision-making and reassurance.

🟣 They may fear abandonment and may tolerate unpleasant situations to maintain support from another person.

🟣 These clients often have trouble initiating tasks, expressing disagreement, or making everyday decisions without advice.

🟣 The expected finding is a pattern of dependence, low self-confidence, and strong fear of being left alone.

The client exhibits splitting behaviors.

🟣Splitting is more commonly associated with borderline personality disorder.

🟣It involves seeing people or situations as all good or all bad.

The client is preoccupied with orderliness.

🟣Preoccupation with orderliness, perfectionism, and control is associated with obsessive-compulsive personality disorder.

🟣Dependent personality disorder centers on needing care and reassurance from others.

The client is suspicious of others.

🟣Suspiciousness and mistrust are associated with paranoid personality disorder.

🟣A dependent client is more likely to seek reassurance than to distrust others.