The nurse is observing a client who is sitting alone in the day room. The client appears intently focused on the empty chair next to him. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he looks over at the chair, whispers something unintelligible, and shakes his head. Based on this observation the nurse would assess the client's behavior as:

Disorganized speech

A hallucination

An illusion

Anhedonia

Answer and Explanation

The Correct Answer is B

A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.

B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.

C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.

D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.

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Correct Answer is D

Explanation

A. Offer the client fluids with meals. Offering fluids with meals may decrease the client's appetite by creating a sense of fullness, which could further reduce calorie intake and not aid in weight gain.

B. Increase fiber in the client's diet. While fiber is important for digestive health, it may also contribute to a feeling of fullness and might not directly help in increasing body weight in clients with anorexia.

C. Encourage the client to eat less protein. Protein is essential for maintaining muscle mass and overall health, especially in clients with AIDS. Reducing protein intake would not be beneficial for weight gain or health maintenance.

D. Provide supplemental vitamins and supplemental nutrition. Offering supplemental nutrition and vitamins can help increase caloric intake and ensure that the client receives essential nutrients to support weight gain and overall health. This is the most appropriate action to help increase the client's body weight.

A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

Correct Answer is B

Explanation

A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.

B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.

C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.

D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has AIDS and anorexia. Which of the following actions should the nurse take to increase the client's body weight?

Correct Answer is D

Explanation

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Correct Answer is B

Explanation

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

The nurse is caring for a client who has has been inhaling solvents to receive a "high." After the nurse provides education on the effects of inhaling solvents, which statement from the client indicates understanding of the teaching?

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?

Clients using antianxiety drugs should be cautious when driving or performing tasks requiring mental alertness because antianxiety drugs may cause:

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

A client's most recent diagnostic imaging has revealed that lung cancer has metastasized to the bones and liver. What is the most likely mechanism by which the client's cancer cells spread?

When administering an antipsychotic medication to a client diagnosed with schizophrenia, which action would be most appropriate for the nurse to include in the client's plan of care? Select all that apply.