A client who has schizophrenia is talking to the nurse and states, "Do you hear that? I am scared. The voices are telling me to do horrible things which of the following responses by the nurse is appropriate?

"You need to understand there are no voices"

What are the voices telling you to do?

What do you think is causing you to heal the voices?

"You need to tell the forces to leave you alone.

Answer and Explanation

The Correct Answer is B

a. "You need to understand there are no voices": Denying the client's experience can be invalidating and unhelpful.
b. What are the voices telling you to do? (Correct)A key principle in responding to someone experiencing auditory hallucinations is to validate their experience and ask open-ended questions. This helps the client feel heard and allows the nurse to assess the severity of the situation and potential safety risks.
c. What do you think is causing you to hear the voices? While exploring the cause of hallucinations can be part of therapy, in the immediate situation, focusing on what the voices are saying and assessing safety is more important.
d. "You need to tell the forces to leave you alone": This is confrontational and doesn't acknowledge the client's fear. It might also reinforce the belief in the voices having power.

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Correct Answer is B

Explanation

a. question the client about choices: This might seem confrontational and does not directly help the client with stressors.
b. explore problem-solving alternatives. This is the most therapeutic purpose. Providing feedback helps the client to consider different ways to address and manage their stressors.
c. express approval or disapproval of the client's thoughts: Expressing approval or disapproval is not therapeutic and can inhibit open communication.
d. give the client good advice: Giving advice is not as effective as helping the client develop their own problem-solving skills.

A. observation during and after meals. B. adherence to scheduled meal times. C. trips to the local fast food restaurant for foods. D. monitoring during bathroom trips. E. weekly weight checks.

Correct Answer is ["A","B","D"]

Explanation

a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.

b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.

c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.

d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.

e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.

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A client who has schizophrenia is talking to the nurse and states, "Do you hear that? I am scared. The voices are telling me to do horrible things which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the mental health nurse's purpose for providing feedback to a client on a psychiatric unit who is verbalizing concerns about stressors? To:

Correct Answer is B

Explanation

When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

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