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 A

Explanation

Choice A rationale
In a client with gastroenteritis experiencing fever, chills, anorexia, and diarrhea, fluid volume deficit is a major concern. Diarrhea and fever can both lead to significant fluid loss. If not addressed, fluid volume deficit can lead to serious complications such as hypovolemic shock.
Choice B rationale
While impaired bed mobility may be a concern due to the client’s history of stroke, it is not the highest priority in this situation. The immediate physiological needs related to the client’s gastroenteritis and potential fluid volume deficit should be addressed first.
Choice C rationale
Caregiver role strain may be a concern given that the client is dependent on care provided by the spouse. However, this psychosocial issue is not the highest priority when the client is experiencing acute physical symptoms that need immediate attention.
Choice D rationale
Bowel incontinence could be a concern for a client with gastroenteritis. However, the risk of fluid volume deficit due to diarrhea and fever is a more immediate concern.

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

Correct Answer is A

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

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