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 A
Explanation
The correct answer is choicea. Teach the client to use a straw when taking the medication to reduce further tooth staining.
Choice A rationale:
Using a straw when taking liquid iron preparations helps minimize contact with the teeth, thereby reducing the risk of staining.
Choice B rationale:
While tooth discoloration can indicate that the iron is being absorbed, it is not a desired effect and should be managed to prevent cosmetic concerns.
Choice C rationale:
Assessing for mouth or gum pain and difficulty swallowing is important but not directly related to the issue of tooth staining.
Choice D rationale:
Advising the client to withhold doses without consulting a healthcare provider could lead to non-compliance and inadequate treatment of iron deficiency.
Correct Answer is C
Explanation
The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:
Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.
Choice B rationale:
Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.
Choice C rationale:
Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.
Choice D rationale:
Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.
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