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The nurse continues to care for the client.

Exhibits

Complete the following sentence by using the lists of options.

The client is at greatest risk for

due to .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Choices:

  • Self-harm: The client expresses suicidal ideation influenced by delusions, indicating a strong risk of acting on these impulses. In schizophrenia, command hallucinations are particularly dangerous when they involve instructions to harm oneself.
  • Command hallucinations: The client reports hearing voices directing them to act, which is a hallmark of command hallucinations. These are associated with a heightened risk of harm to self or others, especially when the client appears fearful or paranoid, as in this case.

Rationale for Incorrect Choices:

  • Palming medications: Although the client is suspicious and refuses medication (“I’m not letting you poison me”), there is no evidence yet of palming or hiding pills. The agitation could indicate refusal, but not covert medication avoidance.
  • Poor hygiene: While the client shows confusion regarding bathing and clothing, these are not the most immediate safety threats compared to suicide risk. Poor hygiene is a concern in schizophrenia but not the most critical issue at this time.
  • Impaired memory: Impaired memory is evident (e.g., forgetting routines), but this is not directly linked to a life-threatening risk. Memory issues can affect functioning but don’t explain the urgency of the client’s safety threat.
  • Distractibility: The client appears distracted at times (e.g., during dressing), but distractibility alone does not account for the risk of self-harm. It contributes to disorganization but is not the main safety concern.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. The client is drinking 2.5 L of water per day: Adequate hydration is important during pregnancy to support blood volume, amniotic fluid levels, and kidney function. A fluid intake of 2.5 liters per day is appropriate and does not raise concerns.

B. The client started working in a parking garage 3 months ago: Parking garages may expose individuals to carbon monoxide and other vehicle exhaust fumes, which can pose risks to fetal development. Prolonged exposure to poor air quality warrants further evaluation for potential harm.

C. The client last visited the dentist 4 months ago: Regular dental care is encouraged during pregnancy due to increased risk of gingivitis and periodontal disease. Visiting the dentist 4 months ago is within a normal range and does not signal unsafe behavior.

D. The client is doing 30 min of moderate exercise daily: Moderate exercise is recommended during pregnancy unless contraindicated. It improves circulation, mood, and energy, and supports healthy weight gain and fetal outcomes.

Correct Answer is D

Explanation

Rationale:

A. Use a mechanical voice amplifier: A voice amplifier benefits clients with impaired vocal strength but does not help clients with expressive aphasia, who struggle to form or express language, not to project it audibly.

B. Provide educational materials with large print: Large print materials are helpful for clients with visual impairments but do not address language expression difficulties. Expressive aphasia requires alternative communication strategies, not visual aids.

C. Have the client's glasses brought from home: Glasses improve vision, not speech or language production. While helpful overall, they do not assist with the core issue of expressive aphasia, which is rooted in brain-language pathways.

D. Establish alternatives to verbal conversation: Using picture boards, writing tools, gestures, or communication apps helps clients express needs and ideas despite speech limitations. These strategies support more effective communication in expressive aphasia.

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