A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the practical nurse (PN) to include in the assessment of this client?
How does the client cope with the voices?.
When are the voices most disturbing?.
Which medication works best?.
What are the voices uttering?.
The Correct Answer is D
The correct answer is Choice D. What are the voices uttering?
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. Knowing what the voices are saying is vital in understanding the nature and potential impact of the hallucinations.
Choice B rationale:
Knowing when the voices are most disturbing can provide some insights into the pattern of the auditory hallucinations. However, this information alone may not fully address the client's current experience or their response to the hallucinations.
Choice C rationale:
Inquiring about which medication works best is important, but it should come after understanding the nature of the hallucinations. Medication management is a crucial aspect of treating schizophrenia, but gathering information about the content of the hallucinations helps in formulating an appropriate treatment plan.
Choice D rationale:
The correct choice. Knowing what the voices are uttering is essential in assessing the severity and potential impact of the auditory hallucinations on the client's well-being. This information will guide the healthcare team in providing targeted interventions and support to manage the symptoms effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.
Choice C rationale:
Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.
Choice D rationale:
Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.
Correct Answer is A
Explanation
The correct answer is Choice A:
Assist in turning the client to one side. Choice A rationale:
When preparing a client with obstructive sleep apnea for sleep, the practical nurse (PN) should assist the client in turning to one side. This position is known as the lateral position and can be beneficial for clients with obstructive sleep apnea. Lying on one's side can help to reduce the likelihood of airway obstruction and minimize the occurrence of apnea (pauses in breathing) during sleep. This position promotes better airflow and can improve the client's overall sleep quality.
Choice B rationale:
Keeping oral suction equipment nearby (Choice B) might be appropriate for clients with respiratory issues or a risk of airway obstruction. However, it is not the best action for a client with obstructive sleep apnea. Sleep apnea primarily involves upper airway collapse, not excessive secretions or obstructions in the oral cavity.
Choice C rationale:
Offering to bring the client a sleeping pill (Choice C) is not an appropriate action for a client with obstructive sleep apnea. Sleep apnea is characterized by repeated episodes of blocked or restricted airflow during sleep. Sedative medications can further relax the muscles in the airway, worsening the condition and potentially leading to more severe apnea.
Choice D rationale:
Placing a cool air humidifier in the room (Choice D) may be helpful for clients who experience dryness or congestion in the airways during sleep. However, it is not specifically indicated for obstructive sleep apnea. While humidifiers can be beneficial for some sleep-related issues, they do not address the underlying cause of sleep apnea.
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.