NCLEX-RN Exam Dumps | A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because

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Question 40/686

A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

A. Sensory-perceptual alteration: auditory command hallucinations

B. Alteration in thought processes: paranoid delusions

C. Potential for violence directed at others

D. Impaired verbal communication: loose associations

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He has suddenl...; Question 394: A 56-year-old client is admitted to the psychiatric unit in ...; Question 395: Children often experience visual impairments. Refractive err...; Question 396: A client's renal calculi are identified as consisting of cal...; Question 397: The nurse is admitting an infant with bacterial meningitis a...; Question 398: The nurse teaches a male client ways to reduce the risks ass...; Question 399: A 27-year-old healthy primigravida is brought to the labor a...; Question 400: A 2-year-old child will undergo a cardiac catheterization to...; Question 401: A client with severe PIH receiving MgSO4 is placed in a quie...; Question 402: A 17-year-old pregnant client who is gravida 1, para 0, is a...; Question 403: A female client has married recently. A month ago she visite...; Question 404: The nurse documents a client's surgical incision as having r...; Question 405: A 28-year-old client performs a long, involved ritual in get...; Question 406: A 55-year-old man is admitted to the hospital with complaint...; Question 407: A 10-year-old boy has been diagnosed with Legg-Calve Perthes...; Question 408: With a geriatric client, the nurse should also assess whethe...; Question 409: After 3 weeks of treatment, a severely depressed client sudd...; Question 410: Discharge teaching was effective if the parents of a child w...; Question 411: A 20-year-old female client delivers a stillborn infant. Fol...; Question 412: At her first prenatal visit, a 21-year-old woman who is grav...; Question 413: The nurse is preparing a 6-year-old child for an IV insertio...; Question 414: A 30-year-old client has a history of several recent traumat...; Question 415: Which of the following activities would be most appropriate ...; Question 416: Which stage of labor lasts from delivery of the baby to deli...; Question 417: A newborn infant is exhibiting signs of respiratory distress...; Question 418: A female client is exhibiting signs of respiratory distress....; Question 419: A chronic alcoholic client's condition deteriorates, and he ...; Question 420: A client in active labor asks the nurse for coaching with he...; Question 421: A client states to his nurse that "I was told by the doctor ...; Question 422: A dose of theophylline may need to be altered if a client wi...; Question 423: Which of the following findings would be abnormal in a postp...; Question 424: A client with IDDM is given IV insulin for a blood glucose l...; Question 425: A female client was recently diagnosed with gastric cancer. ...; Question 426: After 3 weeks of treatment, a severely depressed client sudd...; Question 427: A 45-year-old male client experiences a sense of depression ...; Question 428: A client had a ruptured abdominal aortic aneurysm that was r...; Question 429: A primigravida with a blood type A negative is at 28 weeks' ...; Question 430: A 26-year-old client is diagnosed with an astrocytoma, a ben...; Question 431: A physician's order reads: 0.25 normal saline at 50 mL/hr un...; Question 432: A parent told the public health nurse that her 6-year-old so...; Question 433: The mother of a client is apprehensive about taking home her...; Question 434: The physician orders medication for a client's unpleasant si...; Question 435: A client's membranes have just ruptured spontaneously. Which...; Question 436: Which of the following would indicate the need for further t...; Question 437: A 3-year-old child was hospitalized for acute laryngotracheo...; Question 438: A client is receiving peritoneal dialysis. He has been taugh...; Question 439: A 3-year-old child was hospitalized for acute laryngotracheo...; Question 440: Assessment of a client reveals a 30% loss of preillness weig...; Question 441: Which of the following should be included in discharge teach...; Question 442: The primary focus of nursing interventions for the child exp...; Question 443: A depressed client is seen at the mental health center for f...; Question 444: A client suffering from schizophrenia has been taking chlorp...; Question 445: A 4-week-old infant is admitted to the emergency room in res...; Question 446: A 66-year-old female client has smoked 2 packs of cigarettes...; Question 447: Forty-eight hours after a thyroidectomy, a female client com...; Question 448: A child becomes neutropenic and is placed on protective isol...; Question 449: A female client with major depression stated that "life is h...; Question 450: The nurse is caring for a client who has diabetes insipidus....; Question 451: Following her surgery, a 5-year-old child will return to the...; Question 452: Nursing assessment of early evidence of septic shock in chil...; Question 453: A client has developed congestive heart failure secondary to...; Question 454: A client is being discharged with albuterol (Proventil) and ...; Question 455: A 26-year-old client is admitted to the labor, delivery, rec...; Question 456: A client is a victim of domestic violence. She is now receiv...; Question 457: A 2-year-old child with a scalp laceration and subdural hema...; Question 458: A 24-year-old woman who is gravida 1 reports, "I can't take ...; Question 459: The most commonly known vectors of Lyme disease are:...; Question 460: A 20-year-old male client is being treated for protein defic...; Question 461: A 15-year-old client was diagnosed as having cystic fibrosis...; Question 462: A client is hyperactive and not sleeping. She will not remai...; Question 463: A client with cirrhosis of the liver becomes comatose and is...; Question 464: Parents of young children often need anticipatory guidance f...; Question 465: Which of the following nursing care goals has the highest pr...; Question 466: Assessment of a client reveals a 30% loss of preillness weig...; Question 467: A client was admitted with rib fractures and a pneumothorax,...; Question 468: The doctor has ordered a restricted fluid intake for a 2- ye...; Question 469: Which of the following serum laboratory values would the nur...; Question 470: A schizophrenic client has made sexual overtures toward her ...; Question 471: Which of the following would indicate the need for further t...; Question 472: A client is diagnosed with Mycobacterium tuberculosis. He is...; Question 473: A client had a right below-the-knee amputation 4 days ago. H...; Question 474: What is the appropriate nursing action for a child with incr...; Question 475: Nursing assessment of early evidence of septic shock in chil...; Question 476: Which one of the following is considered a reliable indicato...; Question 477: The postpartum nurse should include which of the following i...; Question 478: The primary reason that an increase in heart rate (100 bpm) ...; Question 479: A client on the infectious disease unit is discussing transm...; Question 480: Hematotympanum and otorrhea are associated with which of the...; Question 481: The nurse is caring for a 6-week-old girl with meningitis. T...; Question 482: Three hours postoperatively, a 27-year-old client complains ...; Question 483: A client was admitted to the hospital after falling in her h...; Question 484: A 38-year-old pregnant woman visits her nurse practitioner f...; Question 485: A client returned to the unit following a pneumonectomy. As ...; Question 486: The nurse enters the playroom and finds an 8-year-old child ...; Question 487: A client is diagnosed with organic brain disorder. The nursi...; Question 488: A 28-year-old woman was admitted to the hospital for a thyro...; Question 489: When a client with pancreatitis is discharged, the nurse nee...; Question 490: Prior to his discharge from the hospital, a cardiac client i...; Question 491: A seventh grader lost consciousness after being hit in the h...; Question 492: An elective saline abortion has been performed on a 3- week ...; Question 493: A client with a head injury asks why he cannot have somethin...; Question 494: A client has been instructed in how to take her nitroglyceri...; Question 495: A 43-year-old client is admitted to the hospital with a diag...; Question 496: A female client decides on hemodialysis. She has an internal...; Question 497: The nurse begins morning assessment on a male client and not...; Question 498: The nurse discovers that a 78-year-old client who received h...; Question 499: Goal setting for a client with Meniere's disease should incl...; Question 500: A first-trimester primigravida is diagnosed with anemia. The...; Question 501: A female client has been diagnosed with chronic renal failur...; Question 502: A new mother experiences strong uterine contractions while b...; Question 503: A baby is circumcised. Immediate postoperative care should i...; Question 504: A client's membranes have just ruptured spontaneously. Which...; Question 505: A 56-year-old psychiatric inpatient has had recurring episod...; Question 506: When a client with pancreatitis is discharged, the nurse nee...; Question 507: A child is admitted with severe headache, fever, vomiting, p...; Question 508: A 28-year-old client comes to the clinic for her first prena...; Question 509: A 26-year-old male client is brought by his wife to the emer...; Question 510: A client undergoes a transurethral resection, prostate (TURP...; Question 511: Which of the following should the nurse anticipate receiving...; Question 512: The nurse is interviewing a client with a diagnosis of possi...; Question 513: During a client's first postpartum day, the nurse assessed t...; Question 514: The therapeutic blood-level range for lithium is:...; Question 515: Nursing care of the infant prior to surgical closure of a me...; Question 516: While changing the dressing on a client's central line, the ...; Question 517: The nurse is caring for a laboring client. Assessment data i...; Question 518: Hematotympanum and otorrhea are associated with which of the...; Question 519: A client has been admitted to the nursing unit with the diag...; Question 520: A 3-year-old child is admitted with a diagnosis of possible ...; Question 521: A nurse is taking a maternal history for a client at her fir...; Question 522: A client presents to the emergency room with cyanosis, cough...; Question 523: An infant weighing 15 lb has just been treated for severe di...; Question 524: A primipara is assessed on arrival to the postpartum unit. T...; Question 525: A client with emphysema is placed on diuretics. In order to ...; Question 526: During the active phase of rheumatic fever, the nurse teache...; Question 527: A 24-hours' postpartum client complains of discomfort at the...; Question 528: The nurse is caring for a 6-week-old girl with meningitis. T...; Question 529: A 30-year-old client has just been treated in the ER for bru...; Question 530: A 23-year-old college student seeks medical attention at the...; Question 531: In evaluating the effectiveness of magnesium sulfate (MgSO4)...; Question 532: The nurse is developing a plan of care for a client with an ...; Question 533: The nurse notes hyperventilation in a client with a thermal ...; Question 534: A 55-year-old client is admitted with a diagnosis of renal c...; Question 535: Nursing care for the parents of a child with a congenital he...; Question 536: A client reports to the nurse that the voices are practicall...; Question 537: A client is experiencing muscle weakness and lethargy. His s...; Question 538: In discussing the plan of care for a child with chronic neph...; Question 539: When evaluating a client with symptoms of shock, it is impor...; Question 540: Which of the following physician's orders would the nurse qu...; Question 541: A client is admitted to the hospital for an induction of lab...; Question 542: A client undergoes a transurethral resection, prostate (TURP...; Question 543: An 80-year-old male client with a history of arteriosclerosi...; Question 544: A 4-year-old child with a history of sickle cell anemia is a...; Question 545: A client on the infectious disease unit is discussing transm...; Question 546: A 60-year-old male client was hospitalized 3 days ago with t...; Question 547: A client returns for her 6-month prenatal checkup and has ga...; Question 548: The nurse recognizes that a client with the diagnosis of cho...; Question 549: A client who has sustained a basilar skull fracture exhibits...; Question 550: Pregnant women with diabetes often have problems related to ...; Question 551: A client has been in labor 10 hours and is becoming very tir...; Question 552: To prevent thrombophlebitis in a client on complete bed rest...; Question 553: A 70-year-old client is almost finished receiving her second...; Question 554: A type I diabetic client is diagnosed with cellulitis in his...; Question 555: The mother of a child taking phenytoin will need to plan app...; Question 556: Which of the following findings would be abnormal in a postp...; Question 557: To prevent transmission of bacterial meningitis, the nurse w...; Question 558: Dietary planning is an essential part of the diabetic client...; Question 559: A 50-year-old depressed client has recently lost his job. He...; Question 560: A 6-year-old girl is visiting the outpatient clinic because ...; Question 561: A female client has been treated since childhood for mitral ...; Question 562: A 30-year-old female client is receiving antineoplastic chem...; Question 563: When planning care for a 9-year-old client, the nurse uses w...; Question 564: A female client at 10 weeks' gestation complains to her phys...; Question 565: A 6-year-old child returned to the surgical floor 20 hours a...; Question 566: A 60-year-old woman exhibits forgetfulness, emotional labili...; Question 567: A 29-year-old client delivered her fifth child by the Lamaze...; Question 568: An infant with a congenital heart defect is being discharged...; Question 569: The nurse would be sure to instruct a client on the signs an...; Question 570: The physician prescribes phenytoin (Dilantin) for a client w...; Question 571: At 30 weeks' gestation, a client is admitted to the unit in ...; Question 572: A physician's order reads: Administer furosemide oral soluti...; Question 573: A male client is experiencing auditory hallucinations. His n...; Question 574: A 40-year-old client is admitted to the hospital for tests t...; Question 575: After a 10-year-old child with insulin-dependent diabetes me...; Question 576: A client is having a pneumonectomy done today, and the nurse...; Question 577: A complication for which the nurse should be alert following...; Question 578: A 25-year-old client is admitted for a tonsillectomy. She te...; Question 579: A 16-year-old client with anorexia nervosa is on an inpatien...; Question 580: A client is experiencing visual problems at school. She has ...; Question 581: Home-care instructions for the child following a cardiac cat...; Question 582: A 22-year-old single woman was admitted to the psychiatric h...; Question 583: A client is pregnant for the fourth time and has had three n...; Question 584: What specific hormone must be present in serum or urine labo...; Question 585: After an infant is delivered by cesarean delivery and placed...; Question 586: A 2-year-old toddler is hospitalized with epiglottitis. In a...; Question 587: A female client has just died. Her family is requesting that...; Question 588: A male client is experiencing extreme distress. He begins to...; Question 589: A 48-year-old client presents with a long history of severed...; Question 590: Nursing care for the parents of a child with a congenital he...; Question 591: Which of the following changes in blood pressure readings sh...; Question 592: An 8-year-old boy has been diagnosed with hemophilia. Which ...; Question 593: A 3-year-old child is in the burn unit following a home acci...; Question 594: Which nursing implication is appropriate for a client underg...; Question 595: A 4-week-old infant is admitted to the emergency room in res...; Question 596: The nurse discovers that a 78-year-old client who received h...; Question 597: What is the appropriate nursing action for a child with incr...; Question 598: A client has chronic obstructive pulmonary disease. She is s...; Question 599: A male client has been hospitalized with congestive heart fa...; Question 600: A six-month-old infant has been admitted to the emergency ro...; Question 601: A client has chronic obstructive pulmonary disease. She is s...; Question 602: A 17-year-old client has a T-4 spinal cord injury. At presen...; Question 603: A 16-year-old diabetic girl has been selected as a cheerlead...; Question 604: A client is to be discharged from the hospital and is to con...; Question 605: When providing dietary teaching to an individual who has dia...; Question 606: The physician orders fluoxetine (Prozac) for a depressed cli...; Question 607: During an examination, the nurse notes that an infant has di...; Question 608: A depressed client is seen at the mental health center for f...; Question 609: When assessing a female child for Turner's syndrome, the nur...; Question 610: A 35-weeks-pregnant client is undergoing a nonstress test (N...; Question 611: When the nurse is evaluating lab data for a client 18-24 hou...; Question 612: A 27-year-old healthy primigravida is brought to the labor a...; Question 613: A 55-year-old man has recently been diagnosed with hypertens...; Question 614: The nurse is teaching a mother care of her child's spica cas...; Question 615: A female client has been treated since childhood for mitral ...; Question 616: A 25-year-old outpatient presents with a diagnosis of compul...; Question 617: The nurse notes hyperventilation in a client with a thermal ...; Question 618: A complication for which the nurse should be alert following...; Question 619: A 3-month-old infant has had a unilateral cleft lip repair. ...; Question 620: One of the medications that is prescribed for a male client ...; Question 621: Following a gastric resection, a 70-year-old client is admit...; Question 622: A client's renal calculi are identified as consisting of cal...; Question 623: A 19-year-old client fell off a ladder approximately 3 ft to...; Question 624: Which of the following findings would necessitate discontinu...; Question 625: An 11-year-old boy has received a partial-thickness burn to ...; Question 626: An 18-year-old client enters the emergency room complaining ...; Question 627: A client on the infectious disease unit is discussing transm...; Question 628: A 23-year-old female client is brought to the emergency room...; Question 629: A client has received preoperative teaching for the vertical...; Question 630: A client is being discharged on warfarin (Coumadin), an oral...; Question 631: Which of the following risk factors associated with breast c...; Question 632: Which of the following would differentiate acute from chroni...; Question 633: The therapeutic blood-level range for lithium is:...; Question 634: A primigravida is at term. The nurse can recognize the secon...; Question 635: The nurse assesses a postoperative mastectomy client and not...; Question 636: What specific hormone must be present in serum or urine labo...; Question 637: A client has had amniocentesis. One of the tests performed o...; Question 638: After a 10-year-old child with insulin-dependent diabetes me...; Question 639: A client is a depressed, 48-year-old salesman. A serious con...; Question 640: A male client is scheduled for a liver biopsy. In preparing ...; Question 641: A 30-year-old male client is admitted to the psychiatric uni...; Question 642: A newborn girl's father expresses concern that the newborn d...; Question 643: Clinical manifestations seen in left-sided rather than in ri...; Question 644: A client with bipolar disorder taking lithium tells the nurs...; Question 645: A client is a depressed, 48-year-old salesman. A serious con...; Question 646: During an examination, the nurse notes that an infant has di...; Question 647: Prenatal clients are routinely monitored for early signs of ...; Question 648: After a 10-year-old child with insulin-dependent diabetes me...; Question 649: A client has been diagnosed as being preeclamptic. The physi...; Question 650: A 2-year-old child with a scalp laceration and subdural hema...; Question 651: When planning care for the passive-aggressive client, the nu...; Question 652: A 17-year-old pregnant client who is gravida 1, para 0, is a...; Question 653: During the active phase of rheumatic fever, the nurse teache...; Question 654: A client has begun to exhibit signs of alcohol withdrawal. H...; Question 655: A 48-year-old female client is going to have a cholecystecto...; Question 656: The physician has ordered that ampicillin 250 mg IV be given...; Question 657: A male client was involved in a motor vehicle accident earli...; Question 658: A 26-year-old female client presents at 10 weeks' gestation....; Question 659: A female client presents to the obstetric-gynecology clinic ...; Question 660: The parents of a 9-year-old child with acute lymphocytic leu...; Question 661: A school-age child with asthma is ready for discharge from t...; Question 662: A 60-year-old woman exhibits forgetfulness, emotional labili...; Question 663: A male client has heart failure. He has been instructed to g...; Question 664: To prevent fungal infections of the mouth and throat, the nu...; Question 665: A child with celiac disease is being discharged from the hos...; Question 666: A 23-year-old female client is brought to the emergency room...; Question 667: Which of the following physician's orders would the nurse qu...; Question 668: A pregnant client is at the clinic for a third trimester pre...; Question 669: In performing the initial nursing assessment on a client at ...; Question 670: A 47-year-old client comes to the emergency department compl...; Question 671: The nurse has been caring for a 16-year-old female who recen...; Question 672: A child sustains a supracondylar fracture of the femur. When...; Question 673: A client is pregnant with her second child. Her last menstru...; Question 674: A 24-year-old graduate student recognizes that he has a phob...; Question 675: A male client has a history of diverticulosis. He has questi...; Question 676: A male client receives 10 U of regular human insulin SC at 9...; Question 677: During the admitting mental health assessment, a client demo...; Question 678: A 24-hours' postpartum client complains of discomfort at the...; Question 679: A 14-year-old client has a history of lying, stealing, and d...; Question 680: A hyperactive client is experiencing flight of ideas. The mo...; Question 681: A 79-year-old client with Alzheimer's disease is exhibiting ...; Question 682: When a client is receiving vasoactive therapy IV, such as do...; Question 683: A client at 6 months' gestation complains of tiredness and d...; Question 684: Which of the following would differentiate acute from chroni...; Question 685: In caring at home for a child who just ingested a caustic al...; Question 686: In an interview for suspected child abuse, the child's mothe...

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