A male college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The client tells the practical nurse (PN) that the voices are saying, "Kill, kill.”. Which question should the PN ask the client next?

The correct answer is choice A: Have the client sit down in the hall.

Choice A rationale: The PN should first have the client sit down to help alleviate the client's chest tightness and shortness of breath. Sitting down allows for better lung expansion and reduces the risk of falling due to dizziness or lightheadedness. This is the most appropriate initial action in response to the client's complaint.

Choice B rationale: While assisting the client back to their room is important, the PN should first ensure that the client is sitting down to help manage their symptoms. After the client is seated and more stable, the PN can then assist them back to their room for further assessment and intervention.

Choice C rationale: Administering sublingual nitroglycerin may be appropriate if the client is experiencing cardiac-related chest pain. However, the PN should first have the client sit down and gather more information about their symptoms before administering any medications.

Choice D rationale: Obtaining a 12-lead electrocardiogram can help assess the client's cardiac status, but it is not the first action that the PN should take in this situation. Ensuring the client's safety and managing their symptoms are immediate priorities. The PN can consider obtaining an electrocardiogram after addressing the client's immediate needs and assessing their condition further.

The correct answer is Choice A:

"Are you planning to obey the voices?.”. Choice A rationale:

The PN should ask the client if he plans to obey the voices because it helps assess the potential risk of harm to himself or others. If the client indicates an intention to follow the voices' commands to harm someone, it indicates a serious concern for safety and may require immediate intervention to protect the client and others.

Choice B rationale:

While asking if the client believes the voices are real is important for understanding the client's perception of the situation, it may not immediately address the risk of harm that the client or others might be facing.

Choice C rationale:

Asking if the client has taken any hallucinogens is relevant to explore possible substance- induced psychosis, but this question should be asked later in the assessment process. The priority is to assess immediate safety concerns related to the client's compliance with the voices' instructions.

Choice D rationale:

Inquiring about when the voices began is important, but it is not the most urgent question in this situation. Although the onset of the symptoms is relevant, addressing the potential for harmful actions should be prioritized.