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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Urinating only once or twice a day is not a typical symptom of type I diabetes mellitus. In fact, frequent urination is a common symptom of diabetes.
Choice B rationale
Rapid weight gain is not typically associated with type I diabetes mellitus. On the contrary, unexplained weight loss is a common symptom.
Choice C rationale
Refusing to eat favorite meals is not a typical symptom of type I diabetes mellitus. Changes in appetite can occur in various conditions, but they are not specific to diabetes.
Choice D rationale
Drinking more fluids than usual, also known as polydipsia, is a common symptom of type I diabetes mellitus. This is often accompanied by polyuria (frequent urination) due to high blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale
Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.
Choice B rationale
Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.
Choice C rationale
While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.
Choice D rationale
Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.