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?

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Question 1 of 5

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?

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.

Question 2 of 5

A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?

Correct Answer: C

Rationale: The correct answer is C. Pacing spikes after the QRS complex indicate a malfunction of the pacemaker and should be reported. Choice A is not directly related to the pacemaker function. Choice B, hiccups, are common and not typically associated with pacemaker issues. Choice D, a heart rate of 90 beats per minute, is within the normal range and does not indicate a pacemaker malfunction.

Question 3 of 5

A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client?

Correct Answer: D

Rationale: The correct answer is D. Food exchange lists from the American Diabetes Association are valuable resources for individuals with diabetes as they provide specific guidance on meal planning and portion control, which are crucial for managing blood sugar levels. Choice A is incorrect because personal blogs may not always provide accurate or evidence-based information. Choice B is incorrect as food label recommendations, while important, may not offer the structured guidance needed for meal planning in diabetes. Choice C is also incorrect as medication information is different from dietary guidance needed for diabetes management.

Question 4 of 5

A nurse is reviewing admission prescriptions for a group of clients. Which prescription should the nurse identify as complete?

Correct Answer: A

Rationale: The correct answer is A. A complete prescription should include the medication name (Furosemide), dosage (20 mg), and administration schedule (BID - twice daily). Choice B is missing the dosage of Aspirin, choice C lacks the dosage information for Nitroglycerin, and choice D does not specify the administration schedule for Metoprolol.

Question 5 of 5

A nurse is reviewing the medical records of a client with a history of depression who is experiencing a situational crisis. What should the nurse do first?

Correct Answer: A

Rationale: Confirming the client's perception of the event is crucial in understanding how they are interpreting the crisis situation. This helps the nurse gain insight into the client's perspective, emotions, and needs. By validating the client's perception, the nurse can establish trust and rapport, which are essential in providing effective support during a crisis. Notifying the client's support system (Choice B) may be important but should come after understanding the client's perspective. Helping the client identify personal strengths (Choice C) and teaching relaxation techniques (Choice D) are valuable interventions but should follow the initial step of confirming the client's perception to ensure individualized care.

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