A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?
A client who is hearing command hallucinations.
A client who is verbalizing ideas of reference.
A client who is using neologisms.
A client who is demonstrating clang associations.
The Correct Answer is A
Choice A reason: A client who is hearing command hallucinations should be prioritized first because command hallucinations can be particularly dangerous. These hallucinations can involve voices instructing the client to harm themselves or others. Immediate assessment and intervention are crucial to ensure the client's safety and to prevent potential harm. The nurse needs to address the client's safety concerns and implement necessary precautions.
Choice B reason: A client verbalizing ideas of reference, which involve misinterpreting events or remarks as having personal significance, may experience distress and paranoia. While these symptoms require attention and management, they do not typically pose an immediate risk to the client's or others' safety. The nurse should monitor and support the client but prioritize more urgent safety concerns first.
Choice C reason: A client using neologisms, or creating new words that are not understood by others, indicates a thought disorder. While this is a significant symptom that requires intervention, it does not typically pose an immediate risk to safety. The nurse should evaluate the client's communication and thought processes and provide appropriate care.
Choice D reason: A client demonstrating clang associations, which involve linking words based on sound rather than meaning, also indicates a thought disorder. This symptom requires attention, but it does not usually pose an immediate threat to the client's or others' safety. The nurse should assess the client's condition and provide appropriate interventions but prioritize more urgent safety concerns first.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Going to their room alone when feeling overwhelmed may indicate that the client is trying to manage their emotions, but it does not directly address the effectiveness of the safety contract. The goal of the contract is to ensure that the client seeks help and communicates their feelings of self-harm to a healthcare provider.
Choice B reason: Displacing feelings of self-harm until talking to the provider is not a clear indication of the contract's effectiveness. The client may still be at risk of self-harm if they do not have immediate access to the provider. The safety contract aims to encourage the client to seek help and communicate their feelings promptly.
Choice C reason: Suppressing feelings when angry is not a healthy coping mechanism and does not indicate the effectiveness of the safety contract. The contract should promote open communication and seeking help rather than suppressing emotions, which can lead to further distress and potential self-harm.
Choice D reason: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.
Correct Answer is B
Explanation
Choice A reason: Extreme fatigue for several weeks is not a common side effect associated with the implantation of a vagus nerve stimulator. While patients may experience some discomfort and mild fatigue immediately following surgery, it is typically short-term. Prolonged extreme fatigue is not a standard outcome and would warrant further medical evaluation if it occurs.
Choice B reason: Hoarseness or changes in voice is a common side effect after the implantation of a vagus nerve stimulator. The stimulator affects the vagus nerve, which is close to the vocal cords. As a result, stimulation can lead to changes in voice, including hoarseness. Patients should be informed of this potential side effect so they are not alarmed if it occurs.
Choice C reason: It is unrealistic to expect depression to improve within 72 hours after the implantation of a vagus nerve stimulator. While this treatment can be effective for certain individuals with treatment-resistant depression, it generally takes several weeks to months for patients to notice significant improvement in their symptoms. Setting realistic expectations is crucial for patient adherence and satisfaction with the treatment.
Choice D reason: Patients should not assume they can schedule an appointment at any time to turn off the device. The vagus nerve stimulator is implanted as part of a treatment plan, and any changes to its operation should be thoroughly discussed with and managed by the healthcare provider. Turning off the device without proper consultation can impact the effectiveness of the treatment and the patient’s overall health.
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