A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?
"When did these voices begin?"
"Have you taken any hallucinogens?"
"Are you planning to obey the voices?"
"Do you believe the voices are real?"
The Correct Answer is C
A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.
B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.
C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.
D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Furosemide: Furosemide is a diuretic used to reduce fluid overload in cirrhosis, especially in ascites. However, it does not address the elevated ammonia level or the client’s confusion, which are signs of hepatic encephalopathy requiring more specific treatment.
B. Intravenous (IV) human albumin: Albumin may be administered to maintain intravascular volume and reduce ascites, but it does not lower serum ammonia. It is supportive therapy, not the priority intervention for encephalopathy.
C. Lactulose: Lactulose is the treatment of choice because it decreases serum ammonia by promoting its excretion through the stool. It helps improve mental status in clients with hepatic encephalopathy and is the most important prescription in this scenario.
D. Loperamide: Loperamide reduces diarrhea by slowing bowel motility, but in this case, diarrhea is beneficial for eliminating ammonia with lactulose. Using loperamide could worsen encephalopathy by reducing ammonia clearance.
Correct Answer is ["1.3"]
Explanation
- Convert the infant's weight from pounds (lb) to kilograms (kg).
Given weight = 22 lb
Conversion factor = 1 kg = 2.2 lb
Weight (kg) = (Weight in lb / 2.2 lb/kg)
= (22 / 2.2)
= 10 kg.
- Calculate the total daily dose in milligrams (mg/day).
Prescribed dose = 20 mg/kg/day
Total Daily Dose (mg/day) = Weight (kg) x Dose (mg/kg/day)
= 10 kg x 20 mg/kg/day = 200 mg/day.
- Calculate the single dose in milligrams (mg/dose).
Frequency = every 8 hours (3 doses per day)
Single Dose (mg/dose) = (Total Daily Dose / Number of doses per day)
= (200 mg / 3)
= 66.67 mg.
- Calculate the volume in milliliters (mL) to administer per dose.
Available concentration = 250 mg per 5 mL
Volume (mL/dose) = (Single Dose (mg) / Available concentration (mg)) x Available volume (mL)
= (66.67 mg / 250 mg) x 5 mL
= 1.333... mL.
- Round the answer to the nearest tenth.
= 1.3 mL.
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