A male college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The client tells the practical nurse (PN) that the voices are saying, "Kill, kill.”. Which question should the PN ask the client next?
"Are you planning to obey the voices?.".
"Do you believe the voices are real?.".
"Have you taken any hallucinogens?.".
"When did these voices begin?.".
The Correct Answer is A
The correct answer is Choice A:
"Are you planning to obey the voices?.”. Choice A rationale:
The PN should ask the client if he plans to obey the voices because it helps assess the potential risk of harm to himself or others. If the client indicates an intention to follow the voices' commands to harm someone, it indicates a serious concern for safety and may require immediate intervention to protect the client and others.
Choice B rationale:
While asking if the client believes the voices are real is important for understanding the client's perception of the situation, it may not immediately address the risk of harm that the client or others might be facing.
Choice C rationale:
Asking if the client has taken any hallucinogens is relevant to explore possible substance- induced psychosis, but this question should be asked later in the assessment process. The priority is to assess immediate safety concerns related to the client's compliance with the voices' instructions.
Choice D rationale:
Inquiring about when the voices began is important, but it is not the most urgent question in this situation. Although the onset of the symptoms is relevant, addressing the potential for harmful actions should be prioritized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Observe how UAP obtains temperatures.
Choice A rationale:
The PN should first observe how the unlicensed assistive personnel (UAP) obtains temperatures using a tympanic thermometer. This step is essential to determine if there is an error in the technique or if the thermometer is malfunctioning. Correct technique and proper use of equipment are crucial to obtaining accurate and reliable temperature readings.
Choice B rationale:
While returning the thermometer for recalibration might be necessary if the thermometer is indeed faulty, it should not be the first action the PN takes. Observing the UAP's technique will help identify if the issue lies with the equipment or the individual's method.
Choice C rationale:
Demonstrating how to use the equipment might be helpful if the UAP is incorrectly using the thermometer. However, observing the UAP's technique first will help the PN identify if there is a need for retraining or recalibration.
Choice D rationale:
Showing the UAP how to chart temperatures is not the first priority when inconsistent readings are noted. Ensuring the accuracy of temperature measurements is essential for proper patient care and assessment.
Correct Answer is D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
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