The nurse is sitting with a client diagnosed with schizophrenia, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say:
"Please share the joke with me."
"You're laughing. Tell me what's happening."
"Why are you laughing?"
"I don't think I said anything funny."
The Correct Answer is B
Choice A Reason:
Asking the client to share the joke may imply that the nurse believes the client is laughing at a joke, which may not be the case. It's important to recognize that uncontrollable laughter can be a symptom of schizophrenia and not necessarily a response to humor.
Choice B Reason:
This response is open-ended and nonjudgmental, inviting the client to explain their behavior without making assumptions. It allows the client to share their experience, which could be related to an internal stimulus such as a hallucination or simply a response they cannot control.
Choice C Reason:
Asking "Why are you laughing?" could be perceived as confrontational or accusatory. It might make the client feel defensive or misunderstood, especially if the laughter is a symptom of their condition and not something they are doing voluntarily.
Choice D Reason:
Saying "I don't think I said anything funny" focuses on the nurse's perspective rather than the client's experience. It could inadvertently dismiss the client's behavior as inappropriate or unjustified, which is not supportive in a therapeutic relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice a reason:
A history of allergy to iodine is a critical finding to report before a coronary angiography because the contrast dye used in the procedure typically contains iodine. Patients with an iodine allergy may experience severe reactions, including anaphylaxis, which can be life-threatening. Precautions such as premedication with steroids and antihistamines or the use of alternative contrast agents may be necessary.
Choice b reason:
A serum potassium level of 4.0 mEq/L is within the normal range, which is approximately 3.5 to 5.2 mEq/L for adults. Therefore, this finding is not significant and does not need to be reported to the healthcare provider prior to the procedure.
Choice c reason:
A blood pressure reading of 138/90 mmHg is slightly elevated but does not reach the threshold for stage 1 hypertension, which starts at 140/90 mmHg for individuals under 60 years of age. While it should be monitored, it is not an urgent concern that needs to be reported immediately before a coronary angiography unless the patient shows symptoms of hypertensive crisis.
Choice d reason:
An EKG showing atrial fibrillation is an important finding; however, it is not typically a contraindication for coronary angiography unless the patient is hemodynamically unstable or symptomatic. Atrial fibrillation can increase the risk of stroke, but anticoagulation management is usually the focus rather than postponing necessary diagnostic procedures.
Correct Answer is A
Explanation
Choice A Reason:
A positive pregnancy test is crucial information that must be reported immediately as it has significant implications for the patient's health and treatment options. Pregnancy can impact the results of a Schilling's test, which is used to diagnose B12 deficiency anemia, as pregnancy itself can cause changes in B12 metabolism. Therefore, the healthcare provider must be informed to adjust the diagnostic approach and ensure the safety of both the mother and the developing fetus.
Choice B Reason:
While a hemoglobin level of 9.5 g/dL is below the normal range for adult females (11.6 to 15 g/dL) and a hematocrit of 32% is at the lower end of the normal range (36% to 44%)[^10^], these results are consistent with anemia but are not as immediately critical as a positive pregnancy test in the context of a Schilling's test.
Choice C Reason:
A glycosylated hemoglobin (A1c) level of 7.5% is above the normal range (4% to 5.9%), indicating poor blood sugar control over the past two to three months, which could suggest diabetes or prediabetes. However, this is not as urgent as a positive pregnancy test when considering the administration of a Schilling's test.
Choice D Reason:
A serum cholesterol level of 237 mg/dL is considered borderline high (200 to 239 mg/dL), which may increase the risk of heart disease over time. However, this does not require immediate reporting in the context of a Schilling's test for B12 deficiency anemia as compared to a positive pregnancy test.
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