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
Choice A rationale:
Offering a high protein diet may not be appropriate for a client with hepatic failure. High protein intake can lead to the accumulation of ammonia in the bloodstream, worsening hepatic encephalopathy. Therefore, this choice is not the best intervention for the client.
Choice B rationale:
Performing range of motion exercises is important for clients with hepatic failure to prevent complications related to immobility. However, it does not directly address the client's elevated pulse rate and changes in mental status.
Choice C rationale:
Weighing the client every morning is essential in monitoring fluid status and identifying signs of fluid retention or dehydration, which are common in hepatic failure. Changes in weight can help detect early signs of worsening hepatic function.
Choice D rationale:
Providing only distilled water may not be appropriate for a client with hepatic failure. While it is essential to monitor fluid intake, restricting all fluids to only distilled water could lead to electrolyte imbalances and further complications. Monitoring overall fluid intake and type is important for these clients.
Correct Answer is B
Explanation
This is the highest priority task and should be completed first because it ensures the safety and quality of care for the clients. The PN should check that all new prescriptions have been administered, documented, and reported as ordered and that there are no errors or omissions.
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