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 C
Explanation
The correct answer is Choice C:
Suggest that an increase in fruits and vegetables is more beneficial.
Choice C rationale:
While dairy products do provide essential nutrients like calcium and vitamin D, there is no strong evidence to suggest that increasing dairy intake alone will significantly reduce the risk of cancer. On the other hand, fruits and vegetables are known to be rich in antioxidants and phytochemicals that have been associated with a reduced risk of cancer. Therefore, suggesting an increase in fruits and vegetables is a more evidence-based approach to reducing cancer risk.
Choice A rationale:
Encouraging exercise is a good recommendation for overall health, but it does not directly address the client's concern about reducing cancer risk. Focusing on a balanced diet, including plenty of fruits and vegetables, is more relevant to the client's specific concern.
Choice B rationale:
Reminding the client about Vitamin D-fortified dairy products may be helpful for addressing Vitamin D intake, but it doesn't necessarily address the broader concern of reducing cancer risk. Moreover, the link between dairy and cancer risk reduction is not as well-established as the benefits of fruits and vegetables.
Choice D rationale:
Providing information about cancer warning signs is important for cancer awareness but doesn't address the client's current dietary choices and concerns about cancer prevention. The focus should be on evidence-based dietary recommendations to reduce cancer risk.
Correct Answer is B
Explanation
The correct answer is choice B, Serum creatinine. Choice A rationale:
The white blood cell count (WBC) is an important parameter for assessing the body's immune response to infections. While it can provide valuable information about the presence of an infection, it is not directly related to nephrotoxicity. Therefore, it is not the most important laboratory value to review before administering an antibiotic that can cause nephrotoxicity.
Choice B rationale:
Serum creatinine is a crucial laboratory value to assess kidney function. It is a waste product that is filtered by the kidneys, and its level in the blood is a reliable indicator of kidney function. If the serum creatinine level is elevated, it suggests impaired kidney function, which can be a warning sign of nephrotoxicity. Reviewing the serum creatinine level before administering nephrotoxic antibiotics is essential to ensure that the client's kidneys are functioning adequately and to avoid potential harm.
Choice C rationale:
Hemoglobin and hematocrit are indicators of the client's red blood cell count and blood's oxygen-carrying capacity. While these values can provide information about the client's overall health status, they are not directly related to nephrotoxicity. Therefore, they are not the most important laboratory values to review in this particular scenario.
Choice D rationale:
Serum calcium levels are essential for assessing bone health, nerve function, and muscle contractions. However, they are not directly related to nephrotoxicity, and reviewing serum calcium levels alone would not provide sufficient information about kidney function. Hence, it is not the most critical value to review before administering nephrotoxic antibiotics
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