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 A

Explanation

A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.

A. Decrease insoluble fiber intake. B. Increase exercise. C. Reduce water intake D. take a laxative every day

Correct Answer is B

Explanation

Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications. Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.

Choice A is wrong because decreasing insoluble fiber intake can worsen constipation. Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.

Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.

Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.

Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.

Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.

Laxatives should be used only as a last resort and under the guidance of a health care provider.

Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

Correct Answer is A

Explanation

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

Correct Answer is B

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?