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?"
"Do you believe the voices are real?"
"Are you planning to obey the voices?"
"Have you taken any hallucinogens?"
The Correct Answer is C
It is important to determine if the client has any plans or intentions to act upon the voices' instructions. This information helps gauge the level of risk and guides further interventions and safety measures.
While the other questions may also be important to ask during the assessment, determining if the client believes the voices are real and when the voices began can provide valuable information about the client's perception and the duration of the symptoms. Asking about the use of hallucinogens is relevant to identify potential substance-induced causes of the hallucinations. However, assessing the client's intent and potential for harm is the priority in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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A. Discuss with provider → Correct. The nurse supports client autonomy and ensures safe management. The provider can adjust the dose, switch medications, or address side effects appropriately.
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B. Side effects dissipate → Incorrect. Some antidepressant side effects improve, but others persist. This statement minimizes the client’s concerns and is not therapeutic.
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C. Gradual tapering → Incorrect. While tapering is necessary, the nurse should not instruct discontinuation independently. This is the provider’s role.
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D. Feeling better is therapeutic effect → Incorrect. Although true, this response dismisses the client’s concern about side effects and does not address the request to discontinue.
Correct Answer is B
Explanation
It is important for the nurse to clarify the client's goals for hospitalization, including the client's understanding of the role of radiation therapy in palliative care. The nurse should also assess the client's understanding of the potential benefits and risks of radiation therapy and communicate this information to the healthcare provider.
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