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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,B,C,A
Explanation
Rationalizing the Priority
1. Airway/Breathing (D):
The "A" and "B" of the ABCs take precedence. In myxedema coma, hypoventilation is a primary concern. The client may experience respiratory muscle weakness or a decreased drive to breathe, leading to CO₂ retention and respiratory failure. Assessing the rate, depth, and effort of breathing is the absolute first step.
2. Circulation (B):
Once the airway is confirmed, you assess the "C" (Circulation). Myxedema coma causes severe bradycardia and decreased cardiac output, which leads to hypotension. Assessing blood pressure tells the nurse if the client is in cardiogenic shock.
3. Vital Signs/Metabolic State (C):
Hypothermia is a hallmark sign of myxedema coma (temperatures can often drop below 95°F or 35°C). While critical, it is addressed after ensuring the heart is pumping and the lungs are moving air. Monitoring temperature is vital because rapid rewarming can actually cause vasodilation and worsen shock.
4. Focused Physical Assessment (A):
Palpating for edema is an important part of a head-to-toe assessment for hypothyroidism (non-pitting mucinous edema is common), but it is not a life-saving intervention. It is a secondary assessment compared to the vital signs and respiratory status.
Correct Answer is D
Explanation
The correct answer is d. hypovolemic.
Choice A reason: This is not a good choice. Septic shock is a type of distributive shock that occurs when an infection causes a systemic inflammatory response that leads to vasodilation, hypotension, and organ dysfunction. Septic shock is not the most common type of shock in children, although it can be a serious and life-threatening condition.
Choice B reason: This is not a good choice. Anaphylactic shock is a type of distributive shock that occurs when an allergic reaction causes a severe and rapid hypersensitivity response that leads to bronchoconstriction, angioedema, and hypotension. Anaphylactic shock is not the most common type of shock in children, although it can be a medical emergency that requires immediate treatment.
Choice C reason: This is not a good choice. Distributive shock is a broad category of shock that occurs when there is a loss of vascular tone and blood volume distribution that leads to hypoperfusion and tissue hypoxia. Distributive shock can be caused by various factors, such as sepsis, anaphylaxis, neurogenic injury, or adrenal insufficiency. Distributive shock is not the most common type of shock in children, although it can be a complex and challenging condition to manage.
Choice D reason: This is the correct choice. Hypovolemic shock is the most common type of shock in children. Hypovolemic shock occurs when there is a loss of blood or fluid volume that leads to decreased preload, cardiac output, and blood pressure. Hypovolemic shock can be caused by various factors, such as hemorrhage, dehydration, vomiting, diarrhea, or burns. Hypovolemic shock can be a life-threatening condition that requires prompt fluid resuscitation and correction of the underlying cause.
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