A nurse is admitting a client who has schizophrenia.

The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

“Have you taken your medication today?”.

“How long have you been hearing the voices?”.

“What are the voices telling you?”.

“I realize the voices are real to you, but I don’t hear anything.”.

Answer and Explanation

The Correct Answer is C

The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.
choice A:
The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental.
choice B
The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time.
choice D
The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation.
The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.

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Correct Answer is A

Explanation

The client has signs of dehydration and oliguria, which are low urine output and dark yellow urine. A fluid bolus can help restore the fluid balance and improve the renal perfusion. The normal urine output for an adult is 0.5-1.5 mL/kg/hr, and the client’s urine output is only 25 mL/hr, which is below the minimum acceptable level. Dark yellow urine can indicate a high concentration of waste products and a low intake of fluids.

Choice B is wrong because continuous bladder irrigation is used to prevent or treat blood clots in the bladder after surgery or injury, not to increase urine output.

Choice C is wrong because a urine specimen for culture and sensitivity is used to diagnose a urinary tract infection, which is not the most likely cause of the client’s low urine output.

The client does not have other symptoms of infection, such as fever, pain, or cloudy urine.

Choice D is wrong because clamping the catheter tubing for 30 min can cause urinary retention, bladder distension, and increased risk of infection.

It can also interfere with the accurate measurement of urine output.

A. Increased Hct. B. Decreased Hgb. C. Increased platelets. D. Decreased WBC count.

Correct Answer is A

Explanation

Hct stands for hematocrit, which is the percentage of red blood cells (RBCs) in the blood. A client who received 2 units of packed RBCs should have an increased Hct because they have more RBCs in their blood volume.

The normal range for Hct is 38% to 50% for males and 36% to 44% for females.

Choice B is wrong because decreased Hgb means decreased hemoglobin, which is the protein that carries oxygen in the RBCs.

A client who received 2 units of packed RBCs should have an increased Hgb because they have more hemoglobin in their blood. The normal range for Hgb is 13.5 to 17.5 g/dL for males and 12 to 15.5 g/dL for females.

Choice C is wrong because increased platelets means increased thrombocytes, which are the cells that help with blood clotting.

A client who received 2 units of packed RBCs should not have an increased platelet count because they did not receive platelets in the transfusion. The normal range for platelets is 150,000 to 400,000/mm^3.

Choice D is wrong because decreased WBC count means decreased leukocytes, which are the cells that fight infection and inflammation.

A client who received 2 units of packed RBCs should not have a decreased WBC count because they did not receive WBCs in the transfusion. The normal range for WBC count is 4,500 to 11,000/mm^3.

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A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

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A nurse is admitting a client who has schizophrenia.

The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?