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.”.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
According to the flashcards from Quizlet, a nurse should monitor a client who is at 33 weeks of gestation following an amniocentesis for contractions, as they are a sign of preterm labor and possible uterine rupture. An amniocentesis is a procedure that involves inserting a needle into the amniotic sac to obtain a sample of amniotic fluid for testing. It can cause complications such as bleeding, infection, leakage of fluid, and injury to the fetus or placenta.
Choice A is wrong because it is not a common complication of amniocentesis.
Epigastric pain is more likely to be associated with preeclampsia, a condition that causes high blood pressure and proteinuria in pregnancy. Epigastric pain can indicate severe preeclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which are life- threatening complications that require immediate medical attention.
Choice B is wrong because it is not a direct result of amniocentesis.
Hypertension can occur in pregnancy due to various factors, such as chronic hypertension, gestational hypertension, preeclampsia, or eclampsia. Hypertension can increase the risk of complications such as placental abruption, fetal growth restriction, preterm birth, and maternal stroke.
Choice D is wrong because it is not a typical complication of amniocentesis.
Vomiting can occur in pregnancy due to various causes, such as morning sickness, gastroenteritis, food poisoning, or hyperemesis gravidarum. Vomiting can lead to dehydration, electrolyte imbalance, weight loss, and malnutrition if not treated properly.
Some normal ranges that are relevant for this question are:
- The normal gestational age for delivery is between 37 and 42 weeks.
A baby born before 37 weeks is considered preterm and may have complications such as respiratory distress syndrome, bleeding in the brain, infection, or low blood sugar.
- The normal fetal heart rate is between 110 and 160 beats per minute.
A fetal heart rate below 110 or above 160 can indicate fetal distress or hypoxia.
- The normal amniotic fluid index (AFI) is between 8 and 18 cm.
An AFI below 5 cm is considered oligohydramnios and can indicate fetal growth restriction, kidney problems, or rupture of membranes.
An AFI above 24 cm is considered polyhydramnios and can indicate fetal anomalies, diabetes mellitus, or Rh incompatibility.
Correct Answer is A
Explanation
This instruction will help the client to prevent venous stasis and thrombosis, which are common postoperative complications. Range-of-motion exercises promote blood circulation and prevent muscle atrophy and contractures.
Choice B is wrong because “Use an incentive spirometer every 4 hours.” is wrong because it is not related to promoting circulation, but rather to improving lung expansion and preventing atelectasis and pneumonia. Using an incentive spirometer is also important for postoperative clients, but it does not address the question.
Choice C is wrong because “Remain on bed rest for 24 hours following the procedure.” is wrong because it is the opposite of promoting circulation.
Bed rest increases the risk of venous stasis, thrombosis, and pulmonary embolism. Postoperative clients should be encouraged to ambulate as soon as possible, unless contraindicated.
Choice D is wrong because “Place a pillow under your knees while in bed.” is wrong because it also impairs circulation and increases the risk of thrombosis.
Placing a pillow under the knees can cause pressure on the popliteal veins and reduce blood flow. Postoperative clients should avoid this position and keep their legs in a neutral or slightly elevated position.
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