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?"

"Do you believe the voices are real?"

"Are you planning to obey the voices?"

"Have you taken any hallucinogens?"

Answer and Explanation

The Correct Answer is C

It is important to determine if the client has any plans or intentions to act upon the voices' instructions. This information helps gauge the level of risk and guides further interventions and safety measures.

While the other questions may also be important to ask during the assessment, determining if the client believes the voices are real and when the voices began can provide valuable information about the client's perception and the duration of the symptoms. Asking about the use of hallucinogens is relevant to identify potential substance-induced causes of the hallucinations. However, assessing the client's intent and potential for harm is the priority in this situation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Incorrect - Developing and implementing new screening protocols does not directly indicate the effectiveness of a primary prevention program. It might indicate improved detection, but not necessarily prevention.
B) Incorrect - This outcome relates to secondary prevention (rehabilitation after disease complications) rather than primary prevention.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is an outcome of early detection (secondary prevention), not primary prevention.

A. Observe the color of urine. B. Assess skin turgor. C. Measure body temperature. D. Check for pedal edema.

Correct Answer is A

Explanation

To monitor for adverse effects from prasugrel, a platelet inhibitor, the nurse should prioritize assessing for bleeding or abnormal bleeding tendencies. Therefore, observing the color of urine is the most important assessment among the options provided.

Changes in urine color, such as the presence of blood or dark-colored urine, can indicate internal bleeding or bleeding in the urinary tract, which can be a potential adverse effect of platelet inhibitors. It is crucial to monitor for signs of bleeding to ensure the client's safety and intervene promptly if necessary.

View Question and Answer

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

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 implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?