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?"
The Correct Answer is A
This is the correct answer because it is the most relevant and respectful question to ask the client next. Asking about the onset of the voices can help the practical nurse (PN) determine the possible causes and triggers of the client's hallucinations, which are sensory perceptions that occur without external stimuli. Hallucinations can be caused by various factors, such as mental disorders, substance abuse, medication side effects, physical illnesses, sleep deprivation, or stress. The PN should ask about the frequency, duration, and content of the voices, as well as the client's response to them. The PN should also assess the client's mood, behavior, cognition, and insight. The PN should use a calm, supportive, and nonjudgmental approach when communicating with the client who is experiencing hallucinations.
a) "Are you planning to obey the voices?"
This is not the correct answer because it is not a priority question to ask the client next. Asking about the client's intention to obey the voices can help the PN assess the risk of harm to self or others, which is an important aspect of safety. However, this question may also imply that the PN believes or validates the voices, which may reinforce the client's delusions or false beliefs. The PN should ask about the client's plan to obey the voices only after establishing rapport and trust with the client, and after assessing the nature and content of the voices.
b) "Have you taken any hallucinogens?"
This is not the correct answer because it is not a respectful question to ask the client next. Asking about the client's substance use can help the PN identify the possible causes of hallucinations, as some drugs such as LSD, psilocybin, or ketamine can induce hallucinogenic effects. However, this question may also sound accusatory or confrontational, which may offend or alienate the client. The PN should ask about the client's substance use in a sensitive and nonthreatening manner, and after obtaining informed consent and ensuring confidentiality.
d) "Do you believe the voices are real?"
This is not the correct answer because it is not a helpful question to ask the client next. Asking about the client's belief in the reality of the voices can help the PN assess the level of insight or awareness that the client has about their condition. However, this question may also challenge or invalidate the client's perception, which may cause defensiveness or resistance. The PN should avoid arguing or disagreeing with the client about their hallucinations, as this may damage the therapeutic relationship. The PN should acknowledge and accept the client's experience without endorsing or reinforcing it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When assessing an older client with left-sided heart failure (HF), the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. Left-sided heart failure is characterized by the inability of the left ventricle to effectively pump blood, leading to fluid accumulation in the lungs. Auscultating all lung fields allows the PN to assess for the presence of abnormal lung sounds such as crackles, indicating pulmonary congestion.
Let's evaluate the other options:
a) Inspect for sacral edema.
Sacral edema is commonly associated with right-sided heart failure, not left-sided heart failure. While it is important to assess for edema in clients with heart failure, inspecting for sacral edema may not be the most immediate and crucial intervention in this specific case.
b) Measure urinary output.
Measuring urinary output is a valuable assessment in many clinical situations, but it may not be the most vital intervention in the context of left-sided heart failure. Monitoring urinary output is more relevant in assessing kidney function and fluid balance rather than directly assessing the severity of left-sided heart failure.
d) Check mental acuity.
Checking mental acuity is important in assessing the overall condition of the client, but it is not the most crucial intervention specifically related to left-sided heart failure. Mental status evaluation is more useful in identifying signs of altered mental status or potential complications, rather than directly assessing the impact of left-sided heart failure.
In summary, when assessing an older client with left-sided heart failure, the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. This allows for the detection of abnormal lung sounds associated with pulmonary congestion, a hallmark sign of left-sided heart failure.
Correct Answer is B
Explanation
Choice A rationale:
Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.
Choice B rationale:
Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.
Choice C rationale:
Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.
Choice D rationale:
Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.
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