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 D
Explanation
Choice A rationale:
Rhinorrhea is not a common adverse effect of baclofen.
Choice B rationale:
Hirsutism (excessive hair growth) is not a common adverse effect of baclofen.
Choice C rationale:
Tachycardia is not a common adverse effect of baclofen.
Choice D rationale:
Constipation is a common adverse effect of baclofen. Baclofen is a muscle relaxant that can affect the gastrointestinal system, leading to reduced bowel motility and constipation.
Correct Answer is C
Explanation
Choice A rationale:
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
Choice B rationale:
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
Choice C rationale:
Rationale:
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers.
Education should provide accurate and evidence-based information to address misconceptions.
Choice D rationale:
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.
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