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?

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
A blood glucose level of 90 mg/dL (5 mmol/L) is within the normal range and would not need to be reported to the surgeon.
Choice B rationale
A serum creatinine level of 5 mg/dL (442 µmol/L) is significantly elevated, indicating impaired kidney function. This is a critical lab value that should be reported to the surgeon immediately, as it could impact the patient’s ability to safely undergo surgery and recover postoperatively.

Choice C rationale
A hemoglobin level of 13 g/dL (130 g/L) is within the normal range and would not need to be reported to the surgeon.
Choice D rationale
A potassium level of 4 mEq/L (4 mmol/L) is within the normal range and would not need to be reported to the surgeon.

A. Stabilize the cervical spine. B. Check for a pulse. C. Request an x-ray. D. Assess the respiratory rate. E. Examine the abdomen. F. Ensure the airway is patent.

Correct Answer is ["A","F"]

Explanation

Choice A rationale

Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.

Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.

Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale

Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing laboratory results for a patient scheduled for a cholecystectomy. Which result is most important for the nurse to report to the surgeon?

Correct Answer is B

Explanation

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?

Correct Answer is ["A","F"]

Explanation

Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? Select all that apply.