A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?
Determine if the client is experiencing command hallucinations.
Arrange for the client to have consistent staff assignments.
Administer lorazepam to the client.
Use the client's name when talking to him.
The Correct Answer is A
Choice A rationale:
Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
Choice B rationale:
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
Choice C rationale:
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
Choice D rationale:
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Eliminating unhealthy foods is generally a good practice, but specific guidance related to managing hyperemesis gravidarum is needed.
Choice B rationale:
Dairy products can be included in the diet unless the client has a specific intolerance or allergy.
Choice C rationale:
Drinking water with each meal can be helpful, but avoiding dehydration is more important. Fluid intake should be consistent throughout the day.
Choice D rationale:
Hyperemesis gravidarum is a condition that causes severe nausea and vomiting during pregnancy, which can lead to dehydration, electrolyte imbalance, and weight loss. To prevent or reduce these complications, the nurse should instruct the client to eat foods at colder temperatures, as they are less likely to trigger nausea than hot or spicy foods. The client should also eat small, frequent meals and avoid foods that are greasy, fatty, or have strong odors.
Correct Answer is B
Explanation
Choice A rationale:
High-impact exercises might not be suitable for all clients and could potentially exacerbate symptoms such as joint pain or discomfort.
Choice B rationale:
Menopause is confirmed after 12 consecutive months without a menstrual period. Until this point, there is still a risk of pregnancy, and contraceptive measures should be used.
Choice C rationale:
Pelvic muscle exercises (Kegel exercises) are important for strengthening pelvic floor muscles but are not specifically related to menopause.
Choice D rationale:
Using a water-based lubricant for painful vaginal intercourse is a helpful suggestion, but it is not the primary focus of menopause education.
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