A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?
Determine if the client is experiencing command hallucinations.
Arrange for the client to have consistent staff assignments.
Administer lorazepam to the client.
Use the client's name when talking to him.
The Correct Answer is A
Choice A rationale:
Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
Choice B rationale:
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
Choice C rationale:
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
Choice D rationale:
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Terbutaline is a medication used to inhibit uterine contractions and is not directly related to managing coarctation of the aorta.
Choice B rationale:
Coarctation of the aorta is a congenital heart defect characterized by narrowing of the aorta, which can lead to increased pressure and decreased blood flow to the lower part of the body. During labor, epidural anesthesia is often recommended for clients with coarctation of the aorta to reduce stress and pain, as well as to maintain stable blood pressure.
Choice C rationale:
Placing a client with coarctation of the aorta in a supine position during labor can worsen the obstruction of blood flow and is contraindicated. Left lateral positioning or other positions that enhance venous return are preferred.
Choice D rationale:
There is no established increased risk of preeclampsia in clients with coarctation of the aorta.
Correct Answer is A
Explanation
Choice A rationale:
Clomiphene is used to induce ovulation in women with infertility. Hot flashes are a common side effect of clomiphene due to its impact on hormone levels. Clomiphene is a medication that stimulates ovulation by blocking estrogen receptors in the hypothalamus and pituitary gland. This causes an increase in the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which stimulate the growth and maturation of ovarian follicles. One of the common side effects of clomiphene is hot flashes, which are caused by the sudden drop in estrogen levels. Hot flashes can be mild or severe, and can occur at any time of the day or night. They usually last for a few minutes and can be accompanied by sweating, palpitations, anxiety, or nausea.
Choice B rationale:
Changes in taste are not a typical side effect of clomiphene.
Choice C rationale:
A dry cough is not typically associated with clomiphene.
Choice D rationale:
Migraine with aura is not typically associated with clomiphene.
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