A nurse is caring for a client who has schizophrenia.
The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?
What are the voices saying to you?
Why are the voices talking to you?
Would you like to go to your therapy session now?
Have you missed your medication today?
The Correct Answer is A
Choice A rationale
Asking about the content of the voices helps the nurse assess for command hallucinations, which can pose a safety risk to the client or others. This open-ended question encourages the client to elaborate, providing crucial information about the severity, nature, and potential danger of the auditory stimuli, which is the primary goal of the assessment.
Choice B rationale
This question is counterproductive because it asks for a causal explanation that the client, due to their altered neurochemical state, cannot provide. It can also be perceived as challenging the reality of the client's experience, which invalidates their feelings and can damage the therapeutic relationship. This is not a therapeutic approach.
Choice C rationale
This redirects the conversation away from the client's immediate distress and the core issue of their hallucinations. While therapy is part of treatment, it may not be appropriate at this moment of crisis. The nurse’s priority is to first assess the immediate risk and support the client's immediate needs, before introducing another activity.
Choice D rationale
Asking about medication adherence can be perceived as accusatory and may cause the client to become defensive. While medication non-adherence can contribute to symptom exacerbation, the immediate priority is to assess the current risk level posed by the hallucinations, not to lecture the client about medication. This question is not therapeutic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While larger gauge catheters (e.g., 18-gauge) are used for rapid infusion, they also cause more trauma to the vein's intimal layer during insertion. This trauma can trigger a localized inflammatory response, increasing the risk of phlebitis, which is inflammation of the vein. Smaller gauge catheters (e.g., 22-24 gauge) cause less trauma and are preferred for routine fluid administration to prevent this complication.
Choice B rationale
The non-dominant arm is the preferred site for IV access whenever possible. Using the non-dominant arm allows the client to maintain more normal function and independence with daily activities, as they can still use their dominant hand without the restriction of the IV line. This also minimizes the risk of accidental dislodgement or trauma to the site.
Choice C rationale
Selecting a site proximal to previous venipuncture sites is the recommended practice. When a vein is punctured, it can cause localized inflammation and scar tissue formation distal to the site. Starting proximal allows for the use of a healthier segment of the vein, which improves the likelihood of successful insertion and reduces the risk of extravasation or phlebitis.
Choice D rationale
The palmar side of the client's wrist should be avoided for IV insertion. This area contains a high concentration of nerves and tendons, including the median nerve and radial artery. Inserting a catheter here increases the risk of nerve damage, which can lead to permanent numbness, tingling, or pain, and also increases the risk of arterial puncture. *.
Correct Answer is A
Explanation
Choice A rationale
Spina bifida is associated with a high incidence of latex allergy due to repeated surgical procedures and catheterizations. There is a documented cross-reactivity between latex proteins and certain food proteins, particularly those found in bananas, avocados, kiwis, and chestnuts. These foods share similar antigenic determinants.
Choice B rationale
Strawberries are not typically associated with latex cross-reactivity. While they can cause allergic reactions in some individuals, the proteins responsible for these allergies do not share the same antigenic structures as those found in natural rubber latex. Therefore, a latex allergy does not necessarily predict a strawberry allergy.
Choice C rationale
Almonds are a tree nut, and while tree nut allergies are common, they are not typically linked to latex cross-reactivity. The allergenic proteins in almonds, such as the major protein Amandin, are structurally different from the proteins found in natural rubber latex, minimizing the risk of a cross-reaction.
Choice D rationale
Hazelnuts, like almonds, are a type of tree nut and are not generally known for cross-reactivity with latex. The proteins that trigger hazelnut allergies do not share significant homology with the proteins in natural rubber latex, so there is no established correlation between a latex allergy and a hazelnut allergy. .
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