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?
"What are the voices telling you?"
"Have you taken your medication today?"
"I realize the voices are real to you, but I don't hear anything."
"How long have you been hearing the voices?"
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.
Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.
Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.
Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. While it’s important to have support during an examination, having multiple nurses present could be overwhelming for the child and may not be necessary. Instead, it's often best to have a single nurse and possibly a pediatric specialist or social worker present, ensuring the child feels safe and comfortable.
B. Incorrect. Reassuring the child that no one will be told is inappropriate as reporting suspected abuse is required by law.
C. Correct. It helps prepare the child for the next steps in the process and can reduce anxiety. Clear communication fosters trust and helps the child understand the importance of reporting for their safety and well-being.
D. Incorrect. Using leading statements can potentially affect the integrity of the investigation.
Correct Answer is D
Explanation
A. Incorrect. Clear liquids are usually introduced slowly and progressively, but 6 hours postoperative might be too soon for this intervention.
B. Incorrect. Cromolyn nebulized solution is used to prevent asthma symptoms triggered by certain factors, not for postoperative care.
C. Incorrect. Applying a warm compress to the operative site might not be appropriate for the immediate postoperative period, especially in the case of appendicitis.
D. Correct. Administering analgesics on a scheduled basis helps manage postoperative pain and provides effective pain relief, promoting comfort and recovery.
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.