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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:

Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.

Choice C rationale:

Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).

Choice D rationale:

Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.

A. "You should avoid temperature extremes." B. "You should engage in high-impact exercise twice per week." C. "You should drink at least 2 liters of fluids each day." D. "You should not receive the influenza vaccine."

Correct Answer is A

Explanation

Choice A rationale:

Avoiding temperature extremes can help prevent triggering a sickle cell crisis. Cold temperatures can cause blood vessels to constrict, leading to poor blood flow and increased risk of cell sickling.

Choice B rationale:

Engaging in high-impact exercise might not be recommended, as vigorous exercise can increase the risk of dehydration and oxygen deprivation, potentially triggering a crisis.

Choice C rationale:

Staying well-hydrated by drinking fluids is important, but temperature regulation is a key factor in preventing sickle cell crises.

Choice D rationale:

Receiving the influenza vaccine is recommended for individuals with sickle cell disease to reduce the risk of infections that could trigger a crisis. This statement is incorrect; the client should receive the influenza vaccine unless contraindicated.

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A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing opioid intoxication. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is teaching a client who has sickle cell disease about preventing a sickle cell crisis. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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