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

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

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

Correct answer: B

Rationale: Asking the client what the voices are saying is the priority action as it helps assess the content of the hallucinations. This assessment is crucial to determine if the client is at risk of harm to themselves or others. Encouraging the client to listen to music or providing a distraction may not address the underlying issues related to the hallucinations. Administering antipsychotic medication, although important, should come after a thorough assessment of the hallucinations to ensure the right medication and dosage are provided.

2. Which of the following are contraindications to salicylic acid therapy?

Correct answer: A

Rationale: The correct answer is A: Third trimester of pregnancy. Salicylic acid is contraindicated during the third trimester of pregnancy due to the risk of complications for both the mother and the fetus. Thrombocytopenia (choice B) is not a contraindication to salicylic acid therapy. Coronary artery disease (choice C) is not a specific contraindication to salicylic acid therapy. However, caution should be exercised in patients with coronary artery disease due to the antiplatelet effects of salicylic acid. Adolescents with chickenpox (choice D) should not be given salicylic acid due to the risk of Reye Syndrome, a rare but serious illness.

3. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?

Correct answer: D

Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.

5. A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?

Correct answer: A

Rationale: Benzodiazepines can increase intraocular pressure, which is why they must be used cautiously in patients with glaucoma. In clients with this condition, benzodiazepines can potentially worsen symptoms and lead to further complications involving the eyes. Therefore, administering benzodiazepines to a client with glaucoma should be done with caution. Choices B, C, and D are not directly contraindicated with benzodiazepines, making them less likely to cause harm compared to administering to a client with glaucoma.

Similar Questions

A nurse is assessing a client with chronic kidney disease. Which laboratory value would indicate the need for hemodialysis?
When providing education on the use of insulin, what should be included?
A healthcare professional is teaching a client about the use of methotrexate. Which of the following should be included?
A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?
A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses