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?"

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Oxytocin is not typically administered during a nonstress test. Oxytocin is a hormone that induces or augments labor contractions; it is not used in nonstress testing, which monitors fetal heart rate and movement. The administration of oxytocin during nonstress testing would not be appropriate or necessary.

Choice B rationale:

Fasting is not required for a nonstress test. Nonstress testing involves attaching electronic fetal monitors to the mother's abdomen to measure the baby's heart rate and movement. It does not require the patient to abstain from eating or drinking. Imposing unnecessary restrictions on the client's diet could cause discomfort and anxiety, which is not conducive to an accurate assessment.

Choice C rationale:

Nonstress testing is used to evaluate the baby's heart rate response to its own movements. It does not diagnose genetic problems. Genetic testing, such as amniocentesis or chorionic villus sampling, is a different type of test used to detect genetic abnormalities in the fetus. Therefore, this statement does not reflect an understanding of the purpose of nonstress testing.

Choice D rationale:

This is the correct answer. Nonstress testing involves monitoring the baby's heart rate and movement. During the test, the mother pushes a button when she feels the baby move. This allows the healthcare provider to correlate fetal movements with changes in the baby's heart rate. An understanding of this process indicates that the client comprehends the purpose and procedure of the nonstress test.

A. Weight loss B. Increased blood pressure C. Decreased pain D. Decreased inflammation

Correct Answer is A

Explanation

A. Correct. Furosemide is a diuretic that promotes the excretion of excess fluid and electrolytes. Weight loss is a direct outcome of diuresis and indicates the effectiveness of furosemide in reducing fluid volume excess.
B. Increased blood pressure is not an expected outcome of furosemide administration.
Furosemide is commonly used to reduce blood pressure in clients with fluid volume excess.
C. Decreased pain and decreased inflammation are not direct outcomes of furosemide administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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