A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?
How do you cope with the voices?
When do you hear the voices?
Which medication works best for you?
What are the voices saying?
The Correct Answer is D
Choice A rationale
While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations.
Choice B rationale
The timing of the voices can provide some insight into the triggers or patterns of the hallucinations, but it does not directly address the content or potential impact of the hallucinations on the client’s behavior or mental state.
Choice C rationale
While medication efficacy is an important aspect of managing schizophrenia, it does not directly address the current experience of the client’s hallucinations.
Choice D rationale
Understanding what the voices are saying to the client can provide critical information about potential risks, including self-harm or harm to others, and can guide the treatment plan. This is why it is the most important question for the nurse to include in the client’s assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.
Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.
Correct Answer is ["B","C","D","E","F","G"]
Explanation
Choice A rationale
Lamb’s wool is typically used for padding to prevent pressure sores and does not directly relate to the administration of oxygen therapy. Therefore, it is not necessary when a patient is put on oxygen.
Choice B rationale
Sterile water is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice C rationale
Tape can be used to secure the oxygen delivery device, such as a nasal cannula, to the patient’s face. Therefore, it is necessary when a patient is put on oxygen.
Choice D rationale
A suction canister is used to collect respiratory secretions during suctioning procedures, which may be necessary for patients with excessive secretions or difficulty clearing secretions.
Therefore, it is necessary when a patient is put on oxygen.
Choice E rationale
A humidifier bottle is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice F rationale
A nasal cannula is a device used to deliver supplemental oxygen to a patient who needs oxygen therapy. Therefore, it is necessary when a patient is put on oxygen.
Choice G rationale
A flowmeter is used in oxygen therapy to control the rate of oxygen flow to the patient. Therefore, it is necessary when a patient is put on oxygen.
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