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 B
Explanation
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the patient’s joint pain, it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice B rationale
Infusing an intravenous fluid bolus is the first intervention that should be implemented in an acute adrenal crisis. This can help to increase the patient’s blood pressure, which is dangerously low.
Choice C rationale
Administering a PRN oral antipyretic could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice D rationale
Covering the patient with a cooling blanket could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Correct Answer is D
Explanation
Choice A rationale
Administering the medication at 1000, 1600, 2200, and 0400 would not be the best schedule because it does not evenly distribute the doses throughout the day. This could lead to periods of subtherapeutic medication levels and periods of potential toxicity.
Choice B rationale
Administering the medication with meals and a bedtime snack is not the best schedule for this medication. While some medications need to be administered with food, there is no indication
that this medication needs to be. Furthermore, this schedule could lead to uneven distribution of the medication throughout the day.
Choice C rationale
Giving the medication in equally divided doses during waking hours is not the best schedule because it does not take into account the half-life of the medication or the patient’s sleep schedule. This could lead to subtherapeutic levels of the medication during the night.
Choice D rationale
Administering the medication at 0800, 1200, 1600, and 2000 is the best schedule for this medication. It evenly distributes the doses throughout the day, which can help maintain a therapeutic level of the medication and reduce the risk of toxicity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.