A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

How do you cope with the voices?

When do you hear the voices?

Which medication works best for you?

What are the voices saying?

Answer and Explanation

The Correct Answer is D

Choice A rationale

While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations.

Choice B rationale

The timing of the voices can provide some insight into the triggers or patterns of the hallucinations, but it does not directly address the content or potential impact of the hallucinations on the client’s behavior or mental state.

Choice C rationale

While medication efficacy is an important aspect of managing schizophrenia, it does not directly address the current experience of the client’s hallucinations.

Choice D rationale

Understanding what the voices are saying to the client can provide critical information about potential risks, including self-harm or harm to others, and can guide the treatment plan. This is why it is the most important question for the nurse to include in the client’s assessment.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale
Periodic sighing and shaking of the head can be signs of agitation and distress. These behaviors may indicate that the client is struggling to manage their emotions and may need additional support or intervention.
Choice B rationale
A decreased activity level and change in affect can be signs of many different mental health conditions, but they are not typically associated with agitation. Therefore, while these behaviors should be monitored, they are not the priority in this situation.
Choice C rationale
Repeated requests for attention from the nurse can be a sign of agitation. This behavior may indicate that the client is feeling distressed and is seeking help in managing their emotions.
Choice D rationale
Argumentativeness and use of profanity are clear signs of agitation. These behaviors can escalate quickly and may pose a risk to the safety of the client and others on the unit.
Therefore, these behaviors should be prioritized for monitoring.

A. Productive cough B. Respiratory rate of 28 breaths/minute C. Oxygen saturation of 90% on room air D. Heart rate of 101 beats/minute E. Capillary refill of 4 seconds F. Blood pressure of 145/89 mm Hg

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale

A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.

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A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes. Which behaviors should the nurse prioritize for monitoring?

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is ["B","C","D"]

Explanation

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