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

Answer and Explanation

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.

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

Explanation

Choice A rationale:

Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.

Choice B rationale:

Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.

Choice C rationale:

Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.

Choice D rationale:

Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.

Choice E rationale:

Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.

A. Move Client D into an isolation room 24 hours before surgery. B. Ask the dietitian to add a banana to Client C's breakfast tray. C. Increase Client A's oxygen to 4 liters a minute per cannula. D. Verify that Client B has two units of packed cells available.

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Moving Client D into an isolation room 24 hours before surgery is not necessary. The client’s white blood cell (WBC) count is 14,000 mm (14 x 10^9/L), which is higher than the normal range of 5000 to 10,000/mm² (5 to 10 x 10^9/L). This indicates that the client may have an infection. However, it is not standard practice to isolate clients scheduled for surgery based solely on an elevated WBC count. Other factors, such as the presence of specific infectious diseases, would dictate the need for isolation.

Choice B rationale: Asking the dietitian to add a banana to Client C’s breakfast tray is not necessary. The client’s potassium level is 3.8 mEq/L (3.8 mmol/L), which is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, there is no need to increase the client’s potassium intake.

Choice C rationale: Increasing Client A’s oxygen to 4 liters a minute per cannula is not necessary. The client has emphysema and their oxygen saturation is 94%, which is within the normal range. Increasing the oxygen flow rate could lead to oxygen toxicity or suppress the client’s respiratory drive, leading to respiratory depression or failure.

Choice D rationale: Verifying that Client B has two units of packed cells available is the correct intervention. The client’s postoperative hemoglobin level is 8.2 mg/dL (82 g/L), which is lower than the normal range of 14 to 18 g/dL (140 to 180 g/L). This indicates that the client is anemic and may require a blood transfusion. Therefore, it is important to ensure that packed cells are available if needed.

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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

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.

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

Explanation

Correct Answer is D

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?