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 ["100"]
Explanation
Step 1: The child is receiving gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes. The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.
Step 2: We need to find the infusion pump’s regulation in mL/hour.
Step 3: Since the medication is to be infused over 30 minutes, we convert this to hours by dividing by 60. So, 30 minutes is 0.5 hours.
Step 4: The rate of infusion is then the total volume (50 mL) divided by the time in hours (0.5 hours).
Step 5: So, the infusion pump’s regulation is (50 mL ÷ 0.5 hours) = 100 mL/hour.
Correct Answer is B
Explanation
Choice A rationale
While a high-calorie, high-protein diet can be beneficial for patients recovering from surgery or illness, it is not the immediate next step after collecting bone aspirate specimens for culture and sensitivity and applying a cast to a patient’s lower leg. The priority is to address the infection identified through the bone aspirate specimens.
Choice B rationale
Beginning parenteral antibiotic therapy is the appropriate next step after collecting bone aspirate specimens for culture and sensitivity in a patient with osteomyelitis. Osteomyelitis is an infection in the bone, and antibiotics are typically the first line of treatment. Therefore, this choice is the correct answer.
Choice C rationale
Administering antiemetic agents would be appropriate if the patient were experiencing nausea or vomiting. However, there is no indication in the question that the patient is experiencing these symptoms. Therefore, this choice is not the correct answer.
Choice D rationale
Bivalving the cast for distal compromise would be appropriate if there were signs of compromised circulation or nerve function below the level of the cast. However, there is no indication in the question that the patient is experiencing these issues. Therefore, this choice is not the correct answer.
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