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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ask the client about gastrointestinal pain: PPIs reduce gastric acid secretion, which relieves symptoms such as heartburn, epigastric pain, and discomfort related to peptic ulcer disease or GERD. Assessing the client’s report of pain evaluates whether the medication is effective.

B. Auscultate for bowel sounds in all quadrants: Bowel sounds indicate gastrointestinal motility rather than acid suppression. PPIs do not directly affect peristalsis, so auscultation is not a reliable measure of drug effectiveness.

C. Measure the client's fluid intake and output: Fluid balance is important in overall patient care but is not a direct indicator of how well a PPI is working. Intake and output monitoring is more relevant to renal or fluid management.

D. Monitor the client's serum electrolyte levels: Electrolyte monitoring may be necessary with prolonged PPI therapy due to risks such as hypomagnesemia, but it does not provide immediate information on short-term medication effectiveness.

A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. B. Update the client and family regarding the COVID-19 vaccines that are available. C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. D. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.

Correct Answer is D

Explanation

A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days: While educating the client about notifying contacts is important, it does not prevent immediate transmission within the healthcare setting. It is a secondary measure.

B. Update the client and family regarding the COVID-19 vaccines that are available: Providing vaccine information is useful for long-term prevention but does not address the urgent need to reduce the risk of transmission from a potentially contagious client.

C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: Assigning the client to a designated area is important for infection control, but the immediate priority is preventing exposure to others while awaiting placement.

D. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE: Immediate isolation is the most critical action to prevent the spread of COVID-19. This protects other clients, visitors, and staff while testing and further management are arranged.

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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

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Correct Answer is A

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

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