A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange.

Which question should the PN ask the client next?

"Are you planning to obey the voices?"

"Have you taken any hallucinogens?"

"When did these voices begin?"

"Do you believe the voices are real?"

None

Answer and Explanation

The Correct Answer is A

Choice A rationale: Safety is the priority when a client experiences auditory hallucinations. The nurse must determine if the voices are "command hallucinations" that might instruct the client to harm themselves or others.

Choice B rationale: While substance use can cause psychosis, this is a secondary assessment. Identifying immediate risk for violence or self-harm takes precedence over determining the specific chemical etiology of the behavior.

Choice C rationale: Establishing the onset of symptoms helps with chronic versus acute diagnosis, but it does not address the immediate safety risk posed by potentially dangerous instructions from the voices.

Choice D rationale: Assessing the client's insight into their condition is important for long-term treatment planning, but it is less critical than identifying the content and intent of the hallucinations.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale:

Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.

Choice B rationale:

Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.

Choice C rationale:

Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.

Choice D rationale:

Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.

Choice E rationale:

Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.

Choice F rationale:

Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.

A. Protamine sulfate should be given slowly intravenously within 30 minutes of heparin administration. B. Protamine sulfate should be given rapidly intramuscularly within 60 minutes of heparin administration. C. Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration. D. Protamine sulfate should be given rapidly intramuscularly within 30 minutes of heparin administration.

Correct Answer is A

Explanation

Choice A rationale:

Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.

Choice C rationale:

While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.

Choice D rationale:

Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.

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A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

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Naxlex Comprehensive Predictor Exams

When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Correct Answer is ["A","B","C","F"]

Explanation

What are some important nursing considerations for this medication? *.

Correct Answer is A

Explanation

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A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange.

Which question should the PN ask the client next?