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 D
Explanation
A. St. John's wort is an herbal supplement that can interact with antidepressant medications like amitriptyline and should be avoided.
B. Taking amitriptyline on an empty stomach can lead to gastrointestinal upset, so it is better to take it with food.
C. Amitriptyline can have anticholinergic effects, which might lower blood pressure rather than raise it.
D. Correct. Amitriptyline and other antidepressants take a few weeks to reach their full therapeutic effect, so it's important for the client to understand this delayed response.
Correct Answer is ["A","B"]
Explanation
Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg
Heart rate 75min
Respiratory rate 18/min
Explanation:
Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):
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Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
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Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.
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