A nurse is caring for a client who has schizophrenia with an exacerbation of hallucinations. The client states, "I do not understand why the hallucinations have come back." The nurse should explain that which of the following is the reason for the exacerbation of hallucinations?

Boundaries

Relapse

The SE model

Stigma

Answer and Explanation

The Correct Answer is B

Rationale:

A. Boundaries refer to maintaining professional limits in the nurse-client relationship, which is not directly related to the cause of hallucination exacerbation.

B. Relapse is the return of symptoms after a period of improvement, which is a common explanation for the recurrence of hallucinations in a client with schizophrenia.

C. The SE model (Social Ecological Model) is a framework for understanding the various levels of influence on health behaviors and is not a direct cause of hallucinations.

D. Stigma refers to the negative attitudes and beliefs about mental illness, which can affect a client’s self-perception but is not a direct cause of symptom exacerbation.

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Correct Answer is B

Explanation

Rationale:

A. Stage 2 (moderate) of alcohol withdrawal involves symptoms such as increased blood pressure and heart rate, mild confusion, and tremors, but does not typically include hallucinations or severe agitation.

B. Stage 3 (severe) alcohol withdrawal includes severe symptoms such as hallucinations (e.g., seeing spiders), severe agitation, and possible delirium tremens, which are consistent with the client's manifestations.

C. Stage 1 (mild) symptoms generally include mild anxiety and tremors but do not include hallucinations or significant changes in mental status.

D. The client’s manifestations indicate severe withdrawal symptoms, not just a general description.

A. Skin color B. Hemoglobin level C. Fluid intake D. Temperature

Correct Answer is B

Explanation

Rationale:

A. While skin color may be an indicator of overall health, it is not the most crucial data point before administering packed RBCs.

B. The hemoglobin level is the most important data to assess before administering packed RBCs, as it provides direct information about the client’s need for the blood transfusion and helps evaluate the effectiveness of the intervention.

C. Fluid intake is important in overall client assessment but is not as immediately relevant as hemoglobin levels when preparing to administer packed RBCs.

D. Temperature should be monitored to check for any signs of infection, but it is not the primary concern when deciding to proceed with a blood transfusion.

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A nurse is caring for a client who has schizophrenia with an exacerbation of hallucinations. The client states, "I do not understand why the hallucinations have come back." The nurse should explain that which of the following is the reason for the exacerbation of hallucinations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

Correct Answer is B

Explanation

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