A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?

A client who is hearing command hallucinations.

A client who is verbalizing ideas of reference.

A client who is using neologisms.

A client who is demonstrating clang associations.

Answer and Explanation

The Correct Answer is A

Choice A reason: A client who is hearing command hallucinations should be prioritized first because command hallucinations can be particularly dangerous. These hallucinations can involve voices instructing the client to harm themselves or others. Immediate assessment and intervention are crucial to ensure the client's safety and to prevent potential harm. The nurse needs to address the client's safety concerns and implement necessary precautions.

Choice B reason: A client verbalizing ideas of reference, which involve misinterpreting events or remarks as having personal significance, may experience distress and paranoia. While these symptoms require attention and management, they do not typically pose an immediate risk to the client's or others' safety. The nurse should monitor and support the client but prioritize more urgent safety concerns first.

Choice C reason: A client using neologisms, or creating new words that are not understood by others, indicates a thought disorder. While this is a significant symptom that requires intervention, it does not typically pose an immediate risk to safety. The nurse should evaluate the client's communication and thought processes and provide appropriate care.

Choice D reason: A client demonstrating clang associations, which involve linking words based on sound rather than meaning, also indicates a thought disorder. This symptom requires attention, but it does not usually pose an immediate threat to the client's or others' safety. The nurse should assess the client's condition and provide appropriate interventions but prioritize more urgent safety concerns first.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: While this statement might be true, it can come across as dismissive or invalidating the adolescent's feelings. The nurse's goal should be to listen and understand the adolescent's perspective, rather than making assumptions about the parents' intentions.

Choice B reason: This response opens up a conversation about the adolescent's feelings and experiences regarding their relationship with their parents. It shows empathy and a willingness to understand the adolescent's perspective, which can help build trust and rapport. By exploring the relationship, the nurse can gather more information and provide appropriate support and guidance.

Choice C reason: Asking "Why do you think your parents are hard to please?" can come across as confrontational or judgmental. It might make the adolescent feel defensive or misunderstood. The nurse should focus on creating a supportive environment for the adolescent to express their feelings without feeling judged.

Choice D reason: Telling the adolescent that "Things will get better as time goes on" can seem dismissive and may not address the immediate concerns and feelings the adolescent is experiencing. It is important for the nurse to validate the adolescent's feelings and offer support and understanding in the present moment.

A. A systolic blood pressure decrease of 15 mm Hg after standing B. Hypersalivation C. Tinnitus D. A weight loss of 3.6 kg (8 lb) over a 6-month time period

Correct Answer is A

Explanation

Choice A reason: A decrease in systolic blood pressure of 15 mm Hg after standing could indicate orthostatic hypotension, which is a known adverse effect of amitriptyline. Orthostatic hypotension can lead to dizziness, lightheadedness, and falls, posing a significant risk to the patient's safety. Reporting this finding to the provider is crucial for assessing the need for dosage adjustments or alternative treatments.

Choice B reason: Hypersalivation is not a common adverse effect of amitriptyline. While dry mouth is a more typical side effect, hypersalivation would be unusual and might indicate an unrelated issue or an interaction with another medication.

Choice C reason: Tinnitus, or ringing in the ears, is not typically associated with amitriptyline use. While it can occur as a side effect of some medications, it is not commonly linked to this particular drug.

Choice D reason: A weight loss of 3.6 kg (8 lb) over a 6-month period is not generally considered an adverse effect of amitriptyline. Weight changes can occur with many medications, but significant weight loss should be evaluated in the context of the patient's overall health and other medications they may be taking.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of an adolescent who states, "I hate living at home. It's impossible to please my parents." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is taking amitriptyline. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?

A nurse is caring for a client who has a phobia of elevators. Which of the following behavioral strategies should the nurse plan to use to decrease anxiety?

A nurse is working with a group of clients during group therapy. For which of the following client disorders will setting limits serve as an appropriate behavioral management technique?

A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend implementing to assist the client with performing ADLs?

A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?

A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?