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.”.
undefined
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Increase dietary calcium. Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.
Choice B is wrong because prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.
Choice C is wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomach.
Choice D is wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.
Correct Answer is B
Explanation
The correct answer is choice B. Using an electronic messaging system to remind clients when to take medications. Tertiary prevention in healthcare involves measures taken to reduce the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life, and their life expectancy. In the context of an HIV clinic, reminding clients to take their medications can help manage the disease effectively and prevent complications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is incorrect because this is more aligned with primary prevention, which aims to prevent the onset of an illness or injury before the disease process begins.
Choice C rationale:
Providing clients with information about the benefits of exercise is incorrect as this is generally considered a part of primary prevention, promoting general health to prevent various diseases.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is incorrect because this is typically associated with secondary prevention, which involves screening to identify diseases in the earliest stages.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
