A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the practical nurse (PN) to include in the assessment of this client?
How does the client cope with the voices?.
When are the voices most disturbing?.
Which medication works best?.
What are the voices uttering?.
The Correct Answer is D
The correct answer is Choice D. What are the voices uttering?
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. Knowing what the voices are saying is vital in understanding the nature and potential impact of the hallucinations.
Choice B rationale:
Knowing when the voices are most disturbing can provide some insights into the pattern of the auditory hallucinations. However, this information alone may not fully address the client's current experience or their response to the hallucinations.
Choice C rationale:
Inquiring about which medication works best is important, but it should come after understanding the nature of the hallucinations. Medication management is a crucial aspect of treating schizophrenia, but gathering information about the content of the hallucinations helps in formulating an appropriate treatment plan.
Choice D rationale:
The correct choice. Knowing what the voices are uttering is essential in assessing the severity and potential impact of the auditory hallucinations on the client's well-being. This information will guide the healthcare team in providing targeted interventions and support to manage the symptoms effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Explains importance of wearing protective clothing when outdoors.
Choice A rationale:
Maintaining a current immunization schedule is important for overall health, but it is not directly related to Lyme disease prevention or management, as there is no vaccine for Lyme disease in humans.
Choice B rationale:
Wearing a mask when leaving the room is a precaution for airborne diseases, not for Lyme disease, which is transmitted through tick bites.
Choice C rationale:
Disposal of personal tissues in a no-touch receptacle is a general infection control measure but does not specifically address Lyme disease prevention or management.
Choice D rationale:
Wearing protective clothing when outdoors is crucial for preventing tick bites, which are the primary mode of transmission for Lyme disease. This measure directly addresses the prevention of Lyme disease.
Correct Answer is A
Explanation
The correct answer is choice A: Tell her to empty her bladder and call if she has a bloody show.
Choice A rationale:
The client is 39 weeks gestation and experiencing mild, irregular contractions. The fact that her cervix is already 3 cm dilated and the presenting part is at -1 station indicates that she is in early labor. Emptying the bladder can help relieve pressure on the cervix and promote progress in labor. Instructing her to call if she has a bloody show is essential because it could indicate that her labor is advancing, and she may need to come to the labor and delivery unit soon.
Choice B rationale:
Directing her to come to the unit for impending delivery is not appropriate at this stage, as she is only experiencing mild, irregular contractions and is likely in early labor. Coming to the unit too early may lead to unnecessary interventions and discomfort for the client.
Choice C rationale:
Asking the charge nurse for further instructions is not necessary in this situation. The client's condition is not emergent, and the practical nurse can handle the situation appropriately based on the information provided.
Choice D rationale:
Encouraging ambulation until the contractions are regular might be beneficial in some cases to promote labor progress. However, given that the client is already 3 cm dilated and experiencing mild, irregular contractions, it's better to address the issue of bladder emptying and potential bloody show.
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