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 C
Explanation
The correct answer is C. Oriented to person only.
Choice A rationale:
A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.
Choice B rationale:
An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.
Choice C rationale:
Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.
Choice D rationale:
A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.
: 1
Correct Answer is A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
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