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 A
Explanation
The correct answer is choice A: "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.”.
Choice A rationale:
This response shows empathy and understanding, acknowledging the client's feelings and respecting her decision not to look at or discuss the incision. It allows the client to take control of her own emotions and healing process, while also reassuring her that the nurse will be available whenever she feels ready to talk or see the incision.
Choice B rationale:
Telling the client that she will feel better when she sees the incision minimizes her feelings and may be seen as dismissive. It does not address her emotions or concerns and can be counterproductive to building trust and rapport.
Choice C rationale:
Suggesting to call another nurse to be present while showing the wound might make the client feel uncomfortable or pressured. It is essential to establish a therapeutic nurse-client relationship, and forcing the issue could increase the client's distress.
Choice D rationale:
Telling the client that part of recovery is accepting her new body image and needing to look at her incision is insensitive and inappropriate. It is not the nurse's role to dictate how the client should feel about her body or her healing process. Such a response could potentially harm the nurse-client relationship and hinder the client's emotional healing.
Correct Answer is A
Explanation
The correct answer is choicea. Teach the client to use a straw when taking the medication to reduce further tooth staining.
Choice A rationale:
Using a straw when taking liquid iron preparations helps minimize contact with the teeth, thereby reducing the risk of staining.
Choice B rationale:
While tooth discoloration can indicate that the iron is being absorbed, it is not a desired effect and should be managed to prevent cosmetic concerns.
Choice C rationale:
Assessing for mouth or gum pain and difficulty swallowing is important but not directly related to the issue of tooth staining.
Choice D rationale:
Advising the client to withhold doses without consulting a healthcare provider could lead to non-compliance and inadequate treatment of iron deficiency.
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