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.The client should be positioned on the unaffected side after the procedure, not the affected side.
B.The client is usually seated upright and leaning forward during a thoracentesis, not placed in the prone position.
C.Correct. Instructing the client to avoid coughing during the procedure is important to prevent accidental puncture of the lung.
D.Thoracentesis does not typically require NPO status, as it is not a procedure involving the gastrointestinal tract.
Correct Answer is ["A","B","C","E"]
Explanation
Client reports lower back pain and pinkish vaginal discharge.
- Explanation: Lower back pain and pinkish discharge can indicate preterm labor, especially given the client’s history of a previous preterm birth.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
- Explanation: Frequent and strong contractions suggest that labor may be progressing, which is concerning at 33 weeks gestation and needs close monitoring.
FHR baseline 145, minimal variability.
- Explanation: Minimal variability in the fetal heart rate (FHR) can be a sign of fetal distress or a lack of fetal well-being, warranting further evaluation.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
- Explanation: Cervical dilation and effacement at 33 weeks gestation indicate that labor is progressing. Given the client's history of preterm birth, this finding is concerning and requires intervention to try to prevent another preterm delivery.
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.