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.”.
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The Correct Answer is C
The correct answer is choice 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.
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 A).
The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time (choice B).
The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation (choice D).
The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.
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Related Questions
Correct Answer is A
Explanation
Encourage collaboration between the two nurses when making the assignments. This is because collaboration is one of the most effective conflict-resolution strategies in nursing, as it involves finding a mutually beneficial solution that satisfies both parties and improves the quality of care. Collaboration can also foster trust, respect, and teamwork among nurses, which can boost morale and efficiency.
Choice B is wrong because telling the nurses that the assignments will be more equitable in the future does not address the root cause of the conflict or involve the nurses in the decision-making process.
It also implies that the charge nurse admits to being unfair, which can damage their credibility and authority.
Choice C is wrong because asking each nurse to take turns making the assignments does not resolve the conflict, but rather avoids it. Avoidance is one of the least effective conflict management strategies in nursing, as it results in not addressing the issue or finding a common ground.
Avoidance can also lead to resentment, frustration, and poor communication among nurses.
Choice D is wrong because arranging for the nurses to have as few shifts together as possible also does not resolve the conflict, but rather accommodates it. Accommodation is another ineffective conflict management strategy in nursing, as it involves giving in to one party’s demands or preferences at the expense of another’s.
Accommodation can also create a sense of inequality, injustice, and dissatisfaction among nurses.
Normal ranges for conflict-resolution strategies in nursing are not applicable, as different situations may require different approaches.
However, some general guidelines are to use collaboration when both parties have important goals or interests, compromise when both parties have some common ground or willingness to give up something, competition when one party has a clear advantage or authority, avoidance when the conflict is trivial or temporary, and accommodation when one party values harmony or relationships more than their own goals or interests.
Correct Answer is B
Explanation
The correct answer is choice B. Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.
Some of the other choices are wrong because:
- Choice A. Supervise return demonstration of diaphragm use.
This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.
- Choice C. Document the client’s level of understanding about potential adverse effects.
This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.
- Choice D. Teach the client how to insert the diaphragm.
This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.
A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.
It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.
It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.
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