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 ["B","D","E"]

Explanation

A. Heart sounds: Assessing heart sounds is important for general health monitoring, but it is not directly related to the effectiveness of herpes zoster treatment. Shingles primarily affects the skin and nerves, not cardiac function.

B. Pain scale: Shingles often causes severe neuropathic pain, so monitoring pain levels helps determine if antiviral therapy and analgesics are effective. Pain reduction is a key marker of successful treatment.

C. Bowel sounds: Bowel function is not typically affected by herpes zoster, unless complications from medications occur. It is not a standard measure of treatment effectiveness for shingles.

D. Functional ability: Severe shingles pain can limit mobility and self-care activities. Assessing functional ability helps evaluate whether symptom management is improving quality of life and daily functioning.

E. Skin integrity: Shingles causes a painful vesicular rash that can progress to ulceration or secondary infection. Monitoring healing of skin lesions and prevention of complications directly reflects treatment effectiveness.

A. Reorient the client while performing assessment. B. Lower the lighting in the client's room. C. Switch to a familiar topic after acknowledging client's feelings. D. Remind the client that his spouse is deceased. E. Explain the rehabilitation regimen to the client.

Correct Answer is ["B","C"]

Explanation

A. Reorient the client while performing assessment: Reorienting a client with acute dementia during periods of distress can increase confusion and agitation. Forcing orientation is often counterproductive and may escalate anxiety.

B. Lower the lighting in the client's room: Reducing harsh lighting can help decrease overstimulation and agitation, creating a calmer environment for a client experiencing acute confusion or distress.

C. Switch to a familiar topic after acknowledging client's feelings: Validating the client’s emotions and then gently redirecting to familiar topics can reduce anxiety, provide comfort, and improve cooperation without causing confrontation.

D. Remind the client that his spouse is deceased: Confronting the client with reality in a distressed state can increase agitation, fear, and confusion. Reality orientation should be approached cautiously, if at all, during acute episodes.

E. Explain the rehabilitation regimen to the client: While education about care is generally important, a client in acute dementia may not be able to process detailed explanations. This intervention does not address immediate emotional distress or safety.

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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 assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","C"]

Explanation

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