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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

A. Muscle rigidity and stiffness B. constipation and dry mouth C. Tachycardia and hypotension D. Reports of photosensitivity

Correct Answer is A

Explanation

a. Muscle rigidity and stiffness: This is correct because muscle rigidity and stiffness are signs of extrapyramidal symptoms (EPS), which benztropine is prescribed to treat.
b. Constipation and dry mouth: These are common side effects of antipsychotics but do not warrant benztropine, which is specifically used to manage EPS.
c. Tachycardia and hypotension: These are not related to the EPS that benztropine treats. They may require other interventions.
d. Reports of photosensitivity: Photosensitivity is not related to EPS and does not require benztropine.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

Correct Answer is C

Explanation

A client diagnosed with schizophrenia disorder is prescribed haloperidol 50 mg oral BID, benztropine 1 mg oral prn, and zolpidem 10 mg oral hs. Which client behavior would warrant the nurse to administer benztropine?

Correct Answer is A

Explanation

The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to the unlicensed nursing assistant?

The nurse is caring for a client who lost the ability to use their arm. All tests have ruled out any medical diagnosis. The nurse understands that the loss of use of the arm is a symptom of:

A client who is agitated and assaultive and unable to be verbally de-escalated is on the inpatient unit. The doctor ordered medications for the nurse to administer to the client. Which medication would the nurse question?

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

The nurse is providing care for a client diagnosed with dissociative fugue. Which behaviors would the nurse expect to see with this client?

During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

A new nurse orientee asks why a client admitted to the psychiatric unit is placed in seclusion. The nurse precepting the new nurse explains that which of the following is a benefit of seclusion?

A nurse is caring for a client who is diagnosed with a conversion disorder. What actions should the nurse include in the plan of care?