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 ["60"]
Explanation
Step 1: We know that the medication is labeled as “750 mcg/2.4 mL”. This means that every 2.4 mL of the medication contains 750 mcg of teriparatide.
Step 2: We need to find out how many mL of the medication contains 60 mcg of teriparatide. We can set up a proportion to solve this: 750 mcg : 2.4 mL = 60 mcg : x mL Step 3: Solving for x gives us: x = (60 mcg * 2.4 mL) ÷ 750 mcg Step 4: Calculating the above expression gives us: x =
0.192 mL So, the nurse should administer 0.192 mL of the medication to deliver a dose of 60 mcg of teriparatide.
Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.
Choice B rationale
Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.
Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.
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