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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Drowsiness is a symptom of hypothyroidism, not hyperthyroidism (thyrotoxicosis). Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. An overdose or excessive dose of this medication would lead to symptoms of hyperthyroidism, which is the opposite of drowsiness. Instead, clients would likely experience increased energy levels, anxiety, or insomnia.
Choice B rationale
Weight gain is a classic symptom of hypothyroidism, not thyrotoxicosis. When the body's metabolism slows down due to insufficient thyroid hormone, the client may gain weight. A client experiencing thyrotoxicosis from an excessive dose of levothyroxine would typically exhibit a hypermetabolic state, which often leads to unintended weight loss despite an increased appetite.
Choice C rationale
A fever is a sign of an accelerated metabolic rate, which is a key feature of thyrotoxicosis. When thyroid hormone levels become excessively high, the body's basal metabolic rate increases significantly, causing an increase in body temperature. This can manifest as a low-grade fever or even a significant fever in severe cases, requiring immediate medical attention.
Choice D rationale
Bradycardia, or a slow heart rate, is a symptom of hypothyroidism. The heart rate slows down as the body's overall metabolic processes decrease. Thyrotoxicosis is characterized by a rapid heart rate, known as tachycardia. This is due to the excessive stimulation of the cardiovascular system by high levels of thyroid hormone. A normal heart rate is typically between 60 and 100 beats per minute. .
Correct Answer is D
Explanation
Choice A rationale
A guardian's statement that a child fell off a swing is a common and plausible explanation for a fractured arm. This type of injury is consistent with the normal activities of a preschooler, and it does not inherently suggest abuse. The nurse should continue with a thorough physical assessment and gather additional history, but this statement alone is not a red flag.
Choice B rationale
Crying loudly when a fractured arm is moved is a normal, expected reaction to pain. The child is experiencing acute pain from the injury, and any movement of the affected limb would cause a significant increase in discomfort. This is not a warning sign of maltreatment but rather a natural physiological response to a painful stimulus.
Choice C rationale
A guardian wanting to accompany a child to the radiology department is a typical and often protective behavior. Many parents wish to provide emotional support to their child during stressful medical procedures. This action demonstrates parental involvement and concern for the child's well-being and is not indicative of abuse or neglect.
Choice D rationale
A delay in seeking medical care for a significant injury, such as a fractured arm, is a major red flag for child maltreatment. This delay suggests that the guardian may be attempting to hide the cause of the injury or is neglectful of the child's health needs. Timely medical attention for a painful injury is the standard of care. .
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