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?"

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.

Choice B rationale:

Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.

Choice D rationale:

Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. Again, the emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.

A. Serum blood glucose (BG) level. B. Neutrophil count. C. Serum albumin. D. Hematocrit.

Correct Answer is B

Explanation

Choice A rationale:

Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.

Choice C rationale:

Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.

Choice D rationale:

Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

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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

The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Correct Answer is C

Explanation

While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

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The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

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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?