A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

"When did these voices begin?"

"Have you taken any hallucinogens?"

"Are you planning to obey the voices?"

"Do you believe the voices are real?"

Answer and Explanation

The Correct Answer is C

A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.

B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.

C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.

D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.

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Correct Answer is C

Explanation

A. Absent sounds: Absent bowel sounds are abnormal and may indicate an ileus, obstruction, or decreased intestinal motility, requiring further assessment.

B. Pain: Pain elicited during percussion is not a normal finding and may indicate underlying pathology such as inflammation, infection, or organ enlargement.

C. Musical and drumlike: Tympany, which produces a musical, drumlike sound during percussion, is a normal finding over air-filled structures in the abdomen. It indicates the presence of gas in the stomach and intestines, reflecting normal gastrointestinal function.

D. Tenderness: Tenderness on percussion is abnormal and may suggest inflammation, infection, or other abdominal pathology requiring further evaluation.

A. Maintain the client on bedrest. B. Administer the client's routine daily aspirin. C. Encourage a diet high in iron and ascorbic acid. D. Encourage the client to dangle the legs frequently.

Correct Answer is A

Explanation

A. Maintain the client on bedrest: The client’s symptoms are consistent with deep vein thrombosis (DVT). Bedrest with limited movement prevents dislodgment of the clot, which could otherwise travel to the lungs and cause a pulmonary embolism. This is the safest initial intervention while anticoagulation is being started.

B. Administer the client's routine daily aspirin: Aspirin has antiplatelet effects but is not the treatment of choice for acute DVT. Starting aspirin with heparin therapy is not recommended, as it increases the risk of bleeding without additional therapeutic benefit.

C. Encourage a diet high in iron and ascorbic acid: While iron and vitamin C support red blood cell production, this dietary intervention does not address the acute management of a thrombus. It may be useful in anemia prevention but is not a priority here.

D. Encourage the client to dangle the legs frequently: Dangling the legs promotes venous stasis and may worsen the clot or increase the risk of embolization. Clients with DVT should avoid activities that increase venous pooling until cleared by the healthcare provider.

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A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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