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 ["A","C","E"]
Explanation
Rationale for correct choices:
• Pain level presently 3 on a 0 to 10 scale: A reduction in pain from 8/10 to 3/10 indicates that the morphine is effectively alleviating the client’s pain. Effective analgesia allows for improved comfort, participation in breathing exercises, and reduced stress response.
• Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer: Increased inspiratory volume demonstrates improved lung expansion, indicating that pain control is facilitating better respiratory effort. This is especially important to prevent atelectasis and maintain adequate oxygenation after rib fractures.
• Repositions in bed with minimal assistance: Ability to move with less assistance reflects improved comfort and mobility due to effective pain management. This shows the therapeutic effect of analgesia in enabling functional activity without excessive pain.
Rationale for incorrect choices:
• Client reports feeling "sleepy": Sleepiness is a common side effect of morphine, reflecting central nervous system depression rather than a therapeutic effect of pain relief. While mild sedation can accompany effective analgesia, it does not directly indicate improvement in the underlying condition.
• New mild cough noted: The appearance of a new cough is not a direct indicator of therapeutic pain relief. It may reflect airway irritation, increased secretions, or a response to deeper breathing, but it is not a measure of analgesic effectiveness.
• Attempted to get up to the chair, but experienced dizziness with standing: Dizziness indicates a side effect of the opioid (orthostatic hypotension or sedation), not a therapeutic response. This finding requires monitoring and safety interventions.
Correct Answer is ["B","C"]
Explanation
A. Tremors: Benztropine is an anticholinergic used to reduce tremors in Parkinson’s disease, so tremors are not an expected adverse effect of this medication.
B. Urinary retention: Anticholinergic effects of benztropine can decrease bladder contractility, leading to urinary retention, which is a common side effect that clients should monitor.
C. Blurred vision: Benztropine can cause blurred vision due to its anticholinergic effect on the eyes, including pupillary dilation and impaired accommodation. Clients should be cautioned about visual changes.
D. Diarrhea is uncommon with benztropine; in fact, anticholinergic medications more often cause constipation rather than diarrhea.
E. Drooling: Benztropine reduces salivation, so drooling is not expected. The medication may actually help decrease excessive salivation associated with Parkinson’s disease.
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