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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, malaise.
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing.
Malaise is one of the symptoms that may follow these signs of infection.
Choice A, drooling, is wrong because it is not a typical symptom of bacterial pneumonia.
Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
Choice B, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
Choice D, rhinorrhea, is wrong because it is not specific to bacterial pneumonia.
Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Rhinorrhea can sometimes occur with viral pneumonia, but not usually with bacterial pneumonia.
Correct Answer is B
Explanation
The correct answer is B.
Choice A reason: Completing oral hygiene is important for overall health, especially for individuals with cystic fibrosis, as they are at a higher risk for dental problems due to thick mucus that can harbor bacteria. However, oral hygiene does not have a direct impact on the effectiveness of postural drainage. Postural drainage is a technique used to clear mucus from the lungs, and while maintaining oral hygiene is beneficial, it is not a prerequisite for this procedure.
Choice B reason: Using a bronchodilator, such as an ibuterol inhaler, is recommended before postural drainage because it helps to open the airways, making the procedure more effective. Bronchodilators work by relaxing the muscles around the airways, which can become constricted in conditions like cystic fibrosis. This relaxation allows for easier clearance of mucus during postural drainage.
Choice C reason: Pancrelipase is an enzyme supplement used to aid digestion in patients with cystic fibrosis, who often have pancreatic insufficiency. While taking pancrelipase is crucial for nutrient absorption, it is not specifically related to the respiratory treatment of postural drainage. Therefore, it is not necessary to take pancrelipase immediately before this procedure.
Choice D reason: Eating a meal before postural drainage is not recommended. The procedure involves placing the body in positions that facilitate the drainage of mucus from the lungs due to gravity. Having a full stomach can cause discomfort, increase the risk of vomiting, and may hinder the effectiveness of the drainage. It is best to perform postural drainage when the stomach is empty, either before meals or at least 1.5 hours after eating.
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