A nurse is admitting a client who has schizophrenia.

The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

“Have you taken your medication today?”.

“How long have you been hearing the voices?”.

“What are the voices telling you?”.

“I realize the voices are real to you, but I don’t hear anything.”.

Answer and Explanation

The Correct Answer is C

The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.
choice A:
The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental.
choice B
The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time.
choice D
The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation.
The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.

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Correct Answer is B

Explanation

Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors.
Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Choice A is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
Choice C is wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved.
Choice D is wrong because experiencing delusions is not necessarily associated with violence unless they are of a paranoid or persecutory nature.
Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal Guide (VRAG), and the Psychopathy Checklist-Revised (PCL-R). These tools use different scales and criteria to evaluate the likelihood of violent behavior in individuals.

A. Epistaxis. B. Headache. C. Dizziness. D. Shortness of breath.

Correct Answer is C

Explanation

Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss. Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.

Choice A is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.

Choice B is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.

Choice D is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.

Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults. Normal ranges for heart rate are 60 to 100 beats per minute for adults.

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A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

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Naxlex Comprehensive Predictor Exams

A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is admitting a client who has schizophrenia.

The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?