Nokea
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?
- A. Do you understand that the voices are not real?
- B. Why do you think the voices are talking to you?
- C. Have you tried going to a private place when this occurs?
- D. What helps you ignore what you are hearing?
Correct Answer: D
Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.
You may also like to solve these questions
A nurse is providing dietary teaching to a client with irritable bowel syndrome (IBS). What recommendation should be included?
- A. Consume foods high in bran fiber.
- B. Increase intake of milk products.
- C. Sweeten foods with fructose corn syrup.
- D. Increase intake of foods high in gluten.
Correct Answer: A
Rationale: The correct answer is A: Consume foods high in bran fiber. Bran fiber is recommended for clients with IBS as it promotes regularity and helps reduce symptoms. Choices B, C, and D are incorrect. Increasing milk products may exacerbate symptoms in some individuals with IBS due to lactose intolerance. Sweetening foods with fructose corn syrup can worsen symptoms as it is a type of sugar that can lead to gastrointestinal discomfort. Increasing intake of foods high in gluten is not recommended for individuals with IBS, especially those with gluten sensitivity, as it may trigger or worsen symptoms.
A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?
- A. Limit your fluid intake to 3 liters per day.
- B. Increase your fluid intake to 5 liters per day.
- C. Avoid drinking more than 1 liter of fluid per day.
- D. You can drink as much fluid as you want during meals.
Correct Answer: C
Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. Tidaling in the water seal chamber.
- D. Drainage of 75 mL in the first 24 hours.
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
- A. Substernal retractions
- B. Hematuria
- C. Temperature of 37.9°C (100.2°F)
- D. Sneezing
Correct Answer: A
Rationale: Substernal retractions indicate respiratory distress in a sickle-cell client, which can be a sign of acute chest syndrome. This condition is a serious complication of sickle-cell anemia characterized by chest pain, fever, cough, and shortness of breath. Reporting this symptom promptly is crucial for timely intervention. Choice B, hematuria, is not typically associated with acute chest syndrome but may indicate other issues such as a urinary tract infection. Choice C, a temperature of 37.9°C (100.2°F), is slightly elevated but not a specific indicator of acute chest syndrome. Choice D, sneezing, is not a typical symptom of acute chest syndrome and would not warrant immediate reporting to the provider in this context.
The healthcare provider is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?
- A. Hyperthyroidism
- B. Thrombophlebitis
- C. Diverticulosis
- D. Hypocalcemia
Correct Answer: B
Rationale: Thrombophlebitis is a condition characterized by inflammation of a vein, which increases the risk of blood clots. The use of oral contraceptives further elevates the risk of clot formation, making them contraindicated in individuals with thrombophlebitis. Hyperthyroidism (Choice A), diverticulosis (Choice C), and hypocalcemia (Choice D) are not contraindications to the use of oral contraceptives.