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?.".

Answer and Explanation

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.

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Correct Answer is A

Explanation

This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.

B. Fluid volume intake and output is not the most important follow-up assessment for this client and may not reﬂect the current status of the client's ﬂuid balance or blood loss.

C. Volume of peripheral pulses is not the most important follow-up assessment for this client and may not be aﬀected by the unsecured surgical dressing unless it is located on a limb or near a major artery.

D. Incisional pain scale rating is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.

A. Boiled brown rice, 1/2 cup. B. Canned tomato soup, 1/2 cup. C. Fresh orange slices, 1 small. D. Grilled chicken, 3 ounces. E. Vegetables topped with cheddar cheese.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is choice A, C, and D. Choice A rationale: Boiled brown rice is a good option for a client with renal disease needing to limit salt intake. It is low in sodium and does not contribute to fluid retention. Choice B rationale: Canned tomato soup is typically high in sodium, which can lead to fluid retention and increased blood pressure, making it an unsuitable choice for someone with renal disease who needs to limit salt intake. Choice C rationale: Fresh orange slices are low in sodium and high in vitamin C. They do not contribute to fluid retention and are suitable for a client with renal disease on a low-salt diet. Choice D rationale: Grilled chicken, especially if not seasoned with salt, is a low-sodium protein source that fits within the dietary restrictions for a client with renal disease. Choice E rationale: Vegetables are generally a good choice, but topping them with cheddar cheese increases the sodium content significantly, making it an inappropriate choice for someone on a low-salt diet, as cheese is often high in sodium.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?

Correct Answer is A

Explanation

The practical nurse (PN) is reinforcing dietary instructions with a client who has renal disease regarding the need to limit salt intake. Which selections for a lunch meal indicate to the PN that the client is following the diet plan? (Select all that apply.).

Correct Answer is ["A","C","D"]

Explanation

The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? (Select all that apply.).

In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?

Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?

A client who had knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.).

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

When caring for a child with sickle cell disease, the practical nurse (PN) expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?

The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first?