A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

Correct Answer: D

Rationale: The correct answer is D) What helps you ignore the voices? This question is appropriate because it focuses on coping strategies and the client's ability to manage the auditory hallucinations. By asking what helps the client ignore the voices, the nurse is exploring the client's current coping mechanisms and opening a dialogue about potential strategies for symptom management. Option A) Do you understand the voices are not real? is incorrect because it assumes the client has insight into their hallucinations, which may not always be the case. This question does not address coping strategies or provide insight into the client's experiences. Option B) Why do you think the voices are talking to you? is also incorrect as it delves into the content of the hallucinations, which may not be helpful in the moment. It does not address coping mechanisms or provide immediate support for the client. Option C) Have you tried going to a quiet place when this occurs? is incorrect because it suggests a solution without exploring what currently works for the client. It may not be effective for all individuals experiencing auditory hallucinations. In an educational context, it is crucial for nurses to understand the importance of assessing coping strategies when working with clients experiencing hallucinations. By focusing on what helps the client manage their symptoms, nurses can provide more personalized and effective support. Encouraging open communication about coping mechanisms can also empower clients in their own care and recovery process.

Correct Answer: A

Rationale: To calculate the correct rate, use the formula: (4 mcg/kg/min * 80 kg) / 800 mcg in 250 mL = 6 mL/hr. This calculation is based on the dose ordered (4 mcg/kg/min) multiplied by the patient's weight in kg (80 kg), divided by the concentration of the drug available (800 mcg in 250 mL) to be infused over 1 hour. Therefore, the correct answer is 6 mL/hr. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided information.

Correct Answer: C

Rationale: In this scenario, with a fetal heart rate (FHR) baseline of 100/min for 15 minutes, the nurse should suspect maternal hypoglycemia. Maternal hypoglycemia can result in fetal bradycardia, which is defined as an FHR less than 110 beats per minute. Maternal hypoglycemia requires prompt intervention to prevent adverse outcomes for both the mother and the fetus. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) is more likely to present with other signs such as pallor or tachycardia rather than bradycardia. Chorioamnionitis (Choice D) is characterized by maternal fever, uterine tenderness, and foul-smelling amniotic fluid, but it is not directly linked to the FHR baseline being 100/min.

Correct Answer: B

Rationale: The correct answer is B because avoiding cleaning the cat's litter box during pregnancy reduces the risk of toxoplasmosis, which can be harmful to the developing fetus. Choice A is incorrect because visiting someone with chickenpox should be avoided as it is highly contagious. Choice C is incorrect as handwashing after gardening should involve soap and water, not just hot water, for effective infection prevention. Choice D is incorrect because antibiotics are ineffective against viral infections.

Correct Answer: B

Rationale: The correct answer is B. Taking a calcium supplement daily is crucial for clients on glucocorticoid therapy to prevent osteoporosis, a common side effect of long-term use. Choice A is unrelated to glucocorticoid therapy. Choice C, limiting potassium intake, is not necessary for clients on glucocorticoids. Choice D, taking medication consistently in the evening, is important but does not specifically address the side effects of glucocorticoid therapy.