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?"
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Wearing protective goggles is important during suctioning to protect the nurse's eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful coughing, gagging, or sneezing in the client, which may cause secretions or mucus to be expelled forcefully and potentially come into contact with the nurse's eyes. Wearing goggles helps prevent eye exposure and reduces the risk of infection transmission.
Applying a water-soluble lubricant to the catheter may be necessary to facilitate the insertion of the suction catheter into the tracheostomy tube, but it is not the most crucial action to include when performing suctioning.
Instilling normal saline before suctioning is not recommended as it can cause potential harm to the client's airway. Instilling saline can lead to bronchospasm, mucosal damage, and other complications. Suctioning should only be performed when necessary to remove secretions and maintain a patent airway.
Instructing the client to cough as the suction tip is removed is not necessary or recommended. Coughing during the suctioning process can be uncontrolled and may increase the risk of trauma to the airway. The nurse should instead provide supportive care and reassurance to the client throughout the procedure.
Correct Answer is D
Explanation
The rash described, pink papular rash with vesicles, is consistent with erythema toxicum neonatorum, which is a common skin condition that affects up to 50% of newborns. It typically appears within the first few days of life and resolves without treatment within 5-7 days. The rash is benign and does not require any specific treatment or intervention.
The rash is not due to distended oil glands or a medication reaction, and there is no indication in the scenario that the healthcare provider needs to be notified about the rash. Erythema toxicum neonatorum is a self-limited condition that resolves on its own, so reassurance and education for the parents are appropriate interventions.
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