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 ["A","C","E"]

Explanation

Choice A rationale:

Including the family in the discharge teaching is essential, especially when dealing with a client who has communication barriers such as hearing loss and illiteracy. Involving the daughter in the teaching process ensures that she is aware of the client's care needs and can provide support at home.

Choice B rationale:

Encouraging the client to attend reading classes is not a practical intervention for an older adult with hearing loss. Reading classes may not address the immediate communication needs of the client, and the client's primary caregiver, in this case, is the daughter who will provide daily care and support.

Choice C rationale:

Facing the client when speaking is a crucial intervention when dealing with someone who has hearing loss. By facing the client, the nurse ensures that the client can see their lips and facial expressions, which can aid in lip-reading and understanding the communication better.

Choice D rationale:

Speaking loudly when teaching is not always the best approach for clients with hearing loss. While it may seem intuitive to speak loudly, it can distort speech and make it more challenging for the client to understand. Clear and slow speech, along with visual cues, is often more effective.

Choice E rationale:

Providing the daughter with written instructions is essential, especially when the client has limited reading skills. Written instructions can serve as a reference guide for the daughter, helping her provide care and support to her father accurately.

A. Deny the medication aide's request to leave before all medications are given. B. Ask each unlicensed assistive personnel (UAP) to give medications to their assigned residents. C. Assign the remainder of medication administration to another PN who is performing treatments. D. Document why all the medications were not given to each of the residents.

Correct Answer is C

Explanation

The correct answer is Choice C: Assign the remainder of medication administration to another Practical Nurse (PN) who is performing treatments.

Choice A reason: Denying the medication aide’s request to leave before all medications are given does not address the issue at hand and could potentially jeopardize patient care. It is important to acknowledge the medication aide’s request and find an appropriate solution that ensures patient safety and well-being.

Choice B reason: Delegating medication administration to unlicensed assistive personnel (UAP) who may not have the necessary training or authorization could lead to medication errors, adverse drug reactions, or other negative outcomes. It is essential to adhere to the scope of practice guidelines and facility policies when assigning tasks to UAPs.

Choice C reason: Reassigning the medication administration to another PN with the necessary qualifications and training ensures that patients receive their medications in a safe and timely manner. This action aligns with the practical nurse’s responsibility to supervise and delegate tasks appropriately, maintaining patient safety and upholding the standards of care.

Choice D reason: Documenting why medications were not given to each resident is an important aspect of maintaining accurate and comprehensive patient records. However, it does not address the immediate need to administer medications to residents, and it is not a substitute for ensuring that patients receive their prescribed treatments. Documentation should be completed after the appropriate steps have been taken to administer medications or arrange for an alternative solution.

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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

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

Explanation

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge take?

Correct Answer is C

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?