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 B
Explanation
The infant has hypoglycemia, which is a low blood glucose level that can cause jitteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.
The other options are not correct because:
A. Offering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.
C. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.
D. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jitteriness.
Correct Answer is C
Explanation
Choice A rationale:
Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.
Choice B rationale:
Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.
Choice C rationale:
Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.
Choice D rationale:
Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.
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