a nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations which of the following actions should the nurse take

ATI LPN

ATI PN Comprehensive Predictor 2023

1. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

A. Encourage the client to lie down in a quiet room.
B. Ask the client directly what they are hearing.
C. Tell the client that the voices are not real.
D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

2. Which of the following situations can be identified as an ethical dilemma?

A. A nurse demonstrates signs of chemical impairment
B. A family has conflicting feelings about tube feeding for their terminally ill father
C. A nurse overhears a colleague threatening to restrain a patient if they do not stay in bed
D. A client with terminal cancer hesitates to name their spouse as power of attorney

Correct answer: B

Rationale: The correct answer is B. Ethical dilemmas involve conflicting values or feelings. In this situation, the family is conflicted about tube feeding for their terminally ill father, which presents a moral and ethical challenge. Choices A, C, and D do not represent ethical dilemmas. Choice A involves a nurse's impairment, which is a different issue. Choice C involves a nurse's observation of a colleague's threat, which is a patient safety concern. Choice D involves a client's hesitation in naming a spouse as power of attorney, which is a legal and decision-making issue, not necessarily an ethical dilemma.

3. What are key signs of a urinary tract infection (UTI) in older adults?

A. Confusion and increased temperature
B. Painful urination and frequent urination
C. Dizziness and headache
D. Back pain and fever

Correct answer: A

Rationale: The correct answer is A. In older adults, key signs of a UTI often include confusion and increased temperature. Confusion is a common symptom in the elderly when they have a UTI, and an increase in body temperature can indicate an infection. Choices B, C, and D are incorrect because while painful urination and frequent urination are common UTI symptoms in general, they may not be as prominent in older adults. Dizziness, headache, back pain, and fever can be associated with other conditions but are not typically key signs of a UTI in older adults.

4. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?

A. Ensure the client is fasting before the test
B. Provide a warm blanket for the client
C. Apply cold compresses to the client's chest
D. Instruct the client to remain still

Correct answer: D

Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.

5. A client with asthma and a new prescription for an ipratropium inhaler is being taught by a nurse. Which statement by the client indicates an understanding of the teaching?

A. I will rinse my mouth after each use
B. I should wait 5 minutes before taking a second puff
C. I should take this medication when I wake up
D. I should wait 1 minute before taking a second puff

Correct answer: D

Rationale: The correct answer is D because waiting 1 minute between puffs ensures proper absorption of the medication. Choice A is incorrect as rinsing the mouth is not a specific instruction related to using the inhaler. Choice B is incorrect as waiting 5 minutes between puffs is longer than necessary. Choice C is incorrect as the timing of medication administration is not specified in the question.