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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Free Nursing Study Resources

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

Explanation

These are the correct supplies for the PN to gather because they are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site and secure it with paper tape after removing the saline lock.

C. A three mL syringe is not needed to remove a saline lock and may cause confusion or harm if used incorrectly.

E. Sterile gloves are not needed to remove a saline lock and may be wasteful or unnecessary.

A. Obtain the infant's vital signs. B. Administer vitamin K injection. C. Place the ID bands on the infant and mother. D. Observe the infant latching onto the breast.

Correct Answer is C

Explanation

The correct answer is Choice C. Place the ID bands on the infant and mother.

Choice A rationale:

While obtaining the infant's vital signs is important, it is not the priority action before transporting the baby to the nursery. Placing ID bands on the infant and mother ensures proper identification and prevents mix-ups during transportation, which is crucial in the nursery setting.

Choice B rationale:

Administering vitamin K injection is also essential but not the immediate priority before transporting the baby. Vitamin K administration helps prevent bleeding disorders in newborns, but ensuring proper identification and security come first.

Choice C rationale:

The correct choice. Placing ID bands on the infant and mother is the most important action before transporting the baby to the nursery. This step ensures accurate identification and matching between the baby and the mother, preventing any confusion or errors in the hospital setting.

Choice D rationale:

Observing the infant latching onto the breast is important for promoting breastfeeding, but it can be done after ensuring proper identification and safety measures have been taken.

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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) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

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

Explanation

A practical nurse (PN) who works in the nursery is attending the vaginal delivery of a term infant. Which action should the PN complete prior to transporting the baby to the nursery?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior is this client likely to exhibit during cocaine withdrawal?

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