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 C
The correct answer is Choice C
Choice A rationale: This question prematurely assumes the client is experiencing command hallucinations, which are auditory hallucinations instructing the individual to perform specific actions, often dangerous. Scientifically, this bypasses the essential diagnostic step of characterizing the hallucination type. Without understanding onset, frequency, and context, asking about obedience risks escalating paranoia or defensiveness. Psychiatric assessment requires chronological and phenomenological data before evaluating risk. Prematurely probing intent may compromise rapport and hinder accurate clinical evaluation.
Choice B rationale: While substance-induced psychosis is a differential diagnosis, asking about hallucinogen use before establishing the nature and onset of symptoms may be perceived as accusatory. Scientifically, the DSM-5 criteria for substance-induced psychotic disorder require temporal correlation between substance use and symptom onset. Without knowing when the voices began, this question lacks diagnostic precision. A thorough psychiatric history must precede substance screening to avoid bias and ensure accurate etiological classification of hallucinations.
Choice C rationale: Establishing the onset of auditory hallucinations is foundational in psychiatric assessment. Scientifically, the timeline helps differentiate between transient, substance-induced, and chronic psychotic disorders such as schizophrenia. Early onset may suggest prodromal schizophrenia, while abrupt onset could indicate delirium or drug-induced psychosis. Understanding duration also informs risk stratification and treatment planning. This question respects clinical sequencing, allowing the nurse to gather essential data before exploring content, belief, or behavioral response to hallucinations.
Choice D rationale: Exploring the client’s belief about the reality of voices is part of assessing insight, but it should follow initial characterization of the hallucinations. Scientifically, insight evaluation helps determine the severity of psychosis and guides treatment adherence predictions. However, asking this prematurely may confuse or distress the client. Insight is typically assessed after establishing symptom chronology, frequency, and impact. Premature probing of belief risks misinterpretation and may hinder therapeutic engagement in early assessment stages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Slower reaction time is a common age-related change in the neurological system. The processing of sensory information and response time may become slower in older adults due to changes in neural pathways and decreased neurotransmitter activity.
Choice B rationale:
Older adults may experience some difficulty with learning new things due to changes in cognitive function and neural plasticity. This is a common age-related effect on the neurological system.
Choice C rationale:
This statement is incorrect. Older adults typically have fewer neurotransmitters in their brains as they age, which can contribute to cognitive changes and a decline in cognitive function.
Choice D rationale:
Loss of some sense of smell and taste is an age-related change. Older adults may experience a decreased ability to detect and differentiate smells and tastes due to changes in olfactory and gustatory receptors.
Choice E rationale:
This statement is incorrect. Aging does not necessarily lead to an increase in oxygen delivery to brain cells. In fact, there may be a decrease in cerebral blood flow with age in some individuals.
Correct Answer is D
Explanation
Choice A rationale:
Assigning the newly hired unlicensed assistive personnel (UAP) to clients who require the least complex level of care is not the best approach to ensure adequate care for all clients. It may limit the UAP's opportunities for learning and growth and may not fully utilize their skills.
Choice B rationale:
Asking the most experienced UAP to partner with the newly hired UAP is a reasonable approach, but it may not provide a comprehensive solution. It can be beneficial for mentorship and guidance, but it may not address all the clients' needs efficiently.
Choice C rationale:
Reviewing the UAP's skills checklist and experience with the person who hired the UAP is an important step in assessing competency. However, it alone may not ensure adequate care for all clients. Competency assessment should be ongoing and include direct observation of care delivery.
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