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?
"Are you planning to obey the voices?.".
"Do you believe the voices are real?.".
"Have you taken any hallucinogens?.".
"When did these voices begin?.".
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice d. Powerful craving for more.
Rationale:
Cocaine withdrawal symptoms are primarily psychological and emotional, rather than physical. While some physical symptoms may occur, such as fatigue and muscle aches, the most prominent and concerning aspects of withdrawal are intense cravings for the drug.
Here's a breakdown of the other choices and why they are not as likely:
- Choice a. Elevated energy level:Cocaine is a stimulant,so during withdrawal,a person is more likely to experiencedecreased energy and fatigue.
- Choice b. High self-esteem:Cocaine use can initially boost self-esteem,but withdrawal often leads to feelings ofdepression, anxiety, and worthlessness.
- Choice c. Euphoria:Euphoria is one of the main effects of cocaine use,but during withdrawal,the opposite occurs,with individuals experiencingdysphoria, a state of intense negative emotions.
Therefore, the intense craving for more cocaine is the most characteristic behavioral symptom exhibited during cocaine withdrawal. This craving is driven by the brain's adaptation to the drug's presence and the disruption of dopamine and other neurotransmitter systems caused by withdrawal.
Additional Notes:
- The intensity of cocaine withdrawal symptoms can vary depending on several factors,including the severity and duration of cocaine use,individual differences in brain chemistry and genetics,and the presence of co-occurring mental health conditions.
- Seeking professional help for cocaine withdrawal is crucial to manage cravings and other symptoms effectively and increase the chances of successful recovery.
Correct Answer is A
Explanation
Choice B rationale:
The semi-Fowler's position involves elevating the head of the bed to 30-45 degrees, which is useful for clients with respiratory issues to promote lung expansion. However, for auscultation of the posterior lung fields in a client with left lower lobe pneumonia, the lateral, semi-prone position is more appropriate as it allows better access to the specific area of concern.
Choice C rationale:
Placing the client on the right side-lying position may not be as effective for auscultating the left lower lobe, as the target area is located on the opposite side. The lateral, semi-prone position offers better access to the left lower lobe for assessment.
Choice D rationale:
The forward orthopneic position is a sitting position with the arms supported on a table or over the bed. While this position can assist clients with breathing difficulties, it is not suitable for auscultation of the posterior lung fields. The lateral, semi-prone position is moreappropriate for this purpose.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.