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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Advance directives are legal documents that allow a person to express their wishes for medical care in case they become incapacitated or unable to communicate. They do not require a lawyer or a notary to be valid, as long as they follow the state laws and are signed by the person and two witnesses.
Choice A is wrong because it implies that legal representation is necessary for advance directives, which is not true.
A social worker can help the client with other resources or support, but not with finding a lawyer for this purpose.
Choice C is wrong because it suggests that advance directives can be verbal, which is not true. Advance directives must be written and signed to be legally binding.
Verbal agreements may not be honored or remembered by the provider or the family.
Choice D is wrong because it implies that advance directives need legal review, which is not true. Advance directives are personal decisions that do not need to be approved by a lawyer or a court.
Legal review may be helpful in some cases, but it is not mandatory or essential.
Correct Answer is B
Explanation
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because a heart rate of 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because the report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
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