The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?
Uses relaxation techniques for stress reduction.
Expresses an interest in yoga to improve flexibility.
Has tried acupressure for pain relief several years ago.
Has been using herbal supplements without consulting a healthcare provider.
The Correct Answer is D
Choice A Reason:
Uses relaxation techniques for stress reduction.
Using relaxation techniques for stress reduction is generally considered safe and beneficial. Techniques such as deep breathing, meditation, and progressive muscle relaxation can help reduce stress and anxiety without significant risks. Therefore, this information does not require immediate investigation.
Choice B Reason:
Expresses an interest in yoga to improve flexibility.
Expressing an interest in yoga to improve flexibility is also generally safe and beneficial. Yoga can enhance physical flexibility, strength, and mental well-being. Unless the client has specific health conditions that might be affected by certain yoga poses, this information does not require immediate investigation.
Choice C Reason:
Has tried acupressure for pain relief several years ago.
Trying acupressure for pain relief several years ago is not typically a cause for concern. Acupressure is a non-invasive therapy that can help alleviate pain and promote relaxation. Since it was used in the past and not currently, it does not require immediate investigation.
Choice D Reason:
Has been using herbal supplements without consulting a healthcare provider.
This is the correct response. Using herbal supplements without consulting a healthcare provider can be risky because some supplements can interact with prescribed medications or have side effects. It is crucial for the nurse to investigate this information immediately to ensure the client’s safety and prevent potential adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Have a poor prognosis
A poor prognosis in schizophrenia is typically associated with persistent and severe symptoms, lack of response to treatment, and significant functional impairment. While the client’s statement about hearing voices is concerning, it does not necessarily indicate a poor prognosis on its own. Prognosis in schizophrenia is multifactorial and depends on various factors, including the duration of untreated psychosis, adherence to treatment, and the presence of supportive social networks.
Choice B Reason: Are not improving and may be getting worse
This choice suggests that the client’s condition is deteriorating. While the presence of hallucinations can indicate a lack of improvement, it is important to consider the context. The client’s ability to question the hallucination and seek reassurance from the nurse suggests a level of insight that is often associated with better outcomes. Insight into one’s condition is a positive prognostic factor in schizophrenia.
Choice C Reason: Are questioning the hallucination and want reassurance from the nurse
This is the correct answer. The client’s question indicates that they are aware that the voices might not be real and are seeking reassurance from the nurse. This level of insight is crucial in managing schizophrenia, as it can lead to better adherence to treatment and improved outcomes. Insight into the nature of hallucinations and delusions is often a sign of a more favorable prognosis.
Choice D Reason: Will begin to enter the manic phase of their illness
Mania is characterized by elevated mood, increased activity, and other symptoms such as decreased need for sleep and grandiosity. It is more commonly associated with bipolar disorder than schizophrenia. The client’s statement about hearing voices predicting their death does not align with the typical presentation of mania. Therefore, this choice is not applicable in this context.
Correct Answer is ["0.63"]
Explanation
To calculate the correct dose:
- Identify the prescribed dose: 5 mg
- Identify the concentration of the available morphine: 8 mg/mL
- Calculate the volume to be administered:
- Volume (mL) = Prescribed dose (mg) ÷ Concentration (mg/mL)
- Volume (mL) = 5 mg ÷ 8 mg/mL
- Volume (mL) = 0.625 mL
The nurse will give 0.63 mL (rounded to the nearest hundredth) for the correct dose.
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