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 D
Explanation
Choice A rationale
Dark spots or floaters in vision are not a typical post-operative finding for cataract removal. They are more commonly associated with retinal detachment, which is a rare but serious complication. The client should be instructed to report this to the provider immediately.
Choice B rationale
Bruising of the eyelids is not a normal or expected outcome after cataract surgery. The procedure is typically performed with a small incision and does not cause significant trauma to the surrounding tissues, making bruising an uncommon occurrence.
Choice C rationale
Cataract surgery is almost always performed using a local anesthetic, not general anesthesia. A local anesthetic is administered to numb the eye and surrounding area, allowing the client to remain awake and aware during the procedure while feeling no pain.
Choice D rationale
The fundamental principle of cataract surgery is the removal of the clouded, opaque lens and its replacement with a clear, artificial intraocular lens (IOL). This is the definitive treatment for cataracts, restoring visual clarity and function to the eye. *.
Correct Answer is D
Explanation
Choice A rationale
Digoxin slows the heart rate by inhibiting the sodium-potassium pump, which increases intracellular calcium and enhances myocardial contractility. Tachycardia is an increase in heart rate, which is the opposite of the expected effect of digoxin. Bradycardia is a more common sign of digoxin toxicity.
Choice B rationale
Insomnia is not a recognized or common side effect of digoxin toxicity. The central nervous system effects of digoxin toxicity typically include confusion, fatigue, and lethargy. Digoxin does not directly interfere with the sleep-wake cycle in a way that would cause insomnia.
Choice C rationale
Hearing loss is not a known symptom of digoxin toxicity. The drug's primary effects are on the cardiovascular and gastrointestinal systems, and to a lesser extent, the central nervous system. Auditory disturbances are not a typical finding associated with the toxic effects of digoxin.
Choice D rationale
Digoxin toxicity often affects the central nervous system and sensory organs. The drug can cause visual disturbances such as blurred vision, photophobia, and a characteristic yellow-green halo around objects (xanthopsia), which is an early sign of toxicity. This effect is a result of digoxin's impact on neural pathways
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