A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange.

Which question should the PN ask the client next?

"Are you planning to obey the voices?"

"Have you taken any hallucinogens?"

"When did these voices begin?"

"Do you believe the voices are real?"

None

Answer and Explanation

The Correct Answer is A

Choice A rationale: Safety is the priority when a client experiences auditory hallucinations. The nurse must determine if the voices are "command hallucinations" that might instruct the client to harm themselves or others.

Choice B rationale: While substance use can cause psychosis, this is a secondary assessment. Identifying immediate risk for violence or self-harm takes precedence over determining the specific chemical etiology of the behavior.

Choice C rationale: Establishing the onset of symptoms helps with chronic versus acute diagnosis, but it does not address the immediate safety risk posed by potentially dangerous instructions from the voices.

Choice D rationale: Assessing the client's insight into their condition is important for long-term treatment planning, but it is less critical than identifying the content and intent of the hallucinations.

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Correct Answer is B

Explanation

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.

A. The client’s oxygen saturation level is 85%. B. The client is eating less than half of meals C. The client’s heart rate is 110 beats per minute. D. The client is reading a book. E. The client’s blood pressure is 160/90 mmHg.

Correct Answer is ["A","C","E"]

Explanation

The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:

A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.

C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.

E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .

The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:

B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .

D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .

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A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse notes that the client’s oxygen saturation is 88% on room air. What is the priority action by the nurse?

Correct Answer is B

Explanation

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

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A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange.

Which question should the PN ask the client next?