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
This is the group of children that the PN should screen for scoliosis because they are at the highest risk of developing this condition. Scoliosis is a lateral curvature of the spine that usually occurs during the growth spurt before puberty. Girls are more likely than boys to have scoliosis, and the condition tends to worsen during adolescence.
A. High school boys are not at high risk of scoliosis and do not need to be screened unless they have signs or symptoms of the condition.
B. High school girls are at lower risk of scoliosis than middle school girls because they have completed most of their growth spurt and their condition is less likely to progress.
C. Middle school boys are at lower risk of scoliosis than middle school girls because they have a slower growth rate and a later onset of puberty.
Correct Answer is C
Explanation
The correct answer is choice C - Paresthesia, paralysis, pedal pulses, pallor, and pain.
Choice A rationale:
Clear lung sounds, CPM (continuous passive motion) on. While assessing lung sounds and the
use of CPM after knee replacement is essential, it may not be the most critical information to document in the client's electronic medical record (EMR) compared to other potential complications.
Choice B rationale:
Call bell, side rails, bed in low position, and ambulation aids. These are important safety measures and assistive devices for the client's post-operative recovery. While documenting these measures is important, they are not the most crucial findings to be documented in the EMR.
Choice C rationale:
Paresthesia, paralysis, pedal pulses, pallor, and pain. After a total knee replacement, it is crucial to assess the neurovascular status of the affected leg to identify any potential complications like nerve damage, circulatory impairment, or blood clot formation.
Documenting these assessments in the EMR helps monitor the client's progress and identify any changes that may require immediate intervention.
Choice D rationale:
Blood pressure 138/88, pain scale 7, and respirations 22. While monitoring vital signs and pain levels is important, these parameters are not the top priority in this situation.
Neurovascular assessments are more critical for the early detection of complications.
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