A 28-year-old client with schizophrenia is pacing the hallway, appearing frightened and mumbling to themselves. When approached, the client states, "The voices are telling me the staff is trying to poison me." Based on this presentation, which of the following nursing interventions is most appropriate?

"I don’t hear the voices, but I understand they're real to you."

Engage in distraction by challenging the client’s beliefs with logical reasoning.

Avoid approaching the client to prevent reinforcing the hallucination.

"There are no voices. What you’re hearing isn’t real."

Answer and Explanation

The Correct Answer is A

Choice A reason: This response acknowledges the client’s experience without reinforcing the hallucination. It demonstrates empathy, maintains reality orientation, and builds trust, which are crucial therapeutic approaches.

Choice B reason: Challenging hallucinations with logic is not effective and can increase client defensiveness or distress. It may also escalate paranoia rather than reduce it.

Choice C reason: Avoiding the client ignores their distress and can increase isolation. Engagement is necessary to provide reassurance and therapeutic support.

Choice D reason: Directly denying the hallucination can invalidate the client’s experience, leading to mistrust and further paranoia. A more supportive acknowledgment is preferred.

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Correct Answer is A

Explanation

Choice A reason: Nurses have a duty to protect potential victims from harm. Breaking confidentiality is justified to warn the intended victim and involve the healthcare team, consistent with the Tarasoff duty to warn principle.

Choice B reason: Warning the victim without involving the treatment team ignores the collaborative care process and may compromise safety planning.

Choice C reason: Waiting to act places the potential victim at risk and disregards the ethical duty to prevent harm.

Choice D reason: Maintaining confidentiality in this situation endangers others and violates the ethical principle of nonmaleficence.

A. Avoid foods high in tyramine, such as aged cheeses, smoked meats, and fermented products. B. Use over-the-counter cold medications containing pseudoephedrine cautiously. C. Take the medication with food to minimize gastrointestinal upset. D. Avoid driving or operating heavy machinery until the effects are known.

Correct Answer is A

Explanation

Choice A reason: The most critical teaching with MAOIs is to avoid foods containing tyramine. Eating these foods can trigger a hypertensive crisis, a potentially fatal complication.

Choice B reason: Cold medications with pseudoephedrine may also increase blood pressure and should be avoided, but dietary restrictions are more essential because food exposure is more common and life-threatening if overlooked.

Choice C reason: Taking the medication with food may reduce mild gastrointestinal side effects, but this is not the priority safety teaching.

Choice D reason: Avoiding hazardous activities until medication effects are known is general advice for many psychotropic drugs, but it is not specific or lifesaving for MAOI therapy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in a psychiatric unit discovers that a client has disclosed intentions to harm a specific person outside the hospital. Balancing ethical principles, what is the nurse’s most appropriate action?

Correct Answer is A

Explanation

A nurse is educating a client who has been prescribed phenelzine, an MAOI, for treatment-resistant depression. Which of the following instructions is most critical to prevent potentially life-threatening complications associated with this medication?

Correct Answer is A

Explanation

A nurse is caring for a child whose guardians report that the child is consistently unable to speak during class and other social situations. The nurse should identify that the child is experiencing which of the following anxiety disorders?

A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply.)

The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? (Select all that apply.)

A nurse is assessing a client diagnosed with schizophrenia who is exhibiting positive symptoms. Which of the following findings should the nurse expect? (Select all that apply.)

Carl Rogers emphasized a humanistic approach in mental health nursing. Which of the following core concepts is central to his theory and therapeutic work?

A nurse is caring for a client newly prescribed aripiprazole, a third-generation antipsychotic, for the treatment of schizophrenia. Which nursing observation would require the most immediate intervention?

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?