A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?

"I'm sure the voices will go away soon."

"Let's talk about what the voices are saying to you."

"You should talk to your counselor about the voices."

"Tell me what medications you are taking."

Answer and Explanation

The Correct Answer is B

This response acknowledges the client's experience and shows a willingness to understand and address their concerns.

It opens up a dialogue about the hallucinations, allowing the nurse to gather more information and assess the client's current mental state. It also demonstrates empathy and support, which can help build trust between the nurse and the client.

Offering to discuss the voices with the client can also help in developing coping strategies and exploring potential interventions to manage the hallucinations effectively.

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Correct Answer is B

Explanation

Soiled dressings, which may contain infectious materials, should be disposed of in a biohazardous waste container to prevent the spread of infection.

According to standard precautions, a 1:10 bleach solution (1 part bleach to 10 parts water) is recommended for cleaning up blood spills.

Alcohol-based hand rubs are not effective against Clostridium difficile. Handwashing with soap and water is necessary to remove the spores.

Droplet precautions typically require wearing a surgical mask, not a gown and gloves. Gowns and gloves are used in contact precautions.

A. Verify the medication three times with the medication administration record. B. Document medication administration prior to administering medication. C. Administer time-critical medication 60 min before or after the scheduled time. D. Identify the client by using one identifier before giving the medication.

Correct Answer is A

Explanation

a. Verify the medication three times with the medication administration record.

When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.

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A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?

Nursing Test Bank

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