A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

Sit in the chair next to the client.

Listen to what the client is saying.

Escort the client to his room.

Administer a PRN sedative.

Answer and Explanation

The Correct Answer is B

A.   Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B.   Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D.   Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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Correct Answer is D

Explanation

A. Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B. The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D. Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.

A. Marijuana is a highly addictive substance. B. Altering one’s ability to think clearly places self and others at risk. C. Healthcare providers sometimes prescribe marijuana to control nausea. D. Drug use has moral implications that should be discussed with parents.

Correct Answer is B

Explanation

A. While marijuana may not be considered highly addictive compared to some substances, the response should address the potential risks and consequences of marijuana use rather than focusing solely on addiction.
B. This response highlights the immediate concern of altering one's ability to think clearly, emphasizing potential risks to both the individual and others.
C. Healthcare providers prescribing marijuana for specific medical purposes does not directly address the student's concern about recreational use.
D. Discussing moral implications may be a subjective approach and may not provide concrete information about the potential risks associated with marijuana use.

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A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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