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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Free Nursing Study Resources

Correct Answer is C

Explanation

c. New onset of hearing loss.

When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse eﬀect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can aﬀect hearing and balance¹.

A. Tilt your head forward while inhaling. B. Take three quick breaths while depressing the canister. C. Close your mouth around the mouthpiece. D. Exhale immediately after inhaling.

Correct Answer is C

Explanation

Albuterol is a bronchodilator medication that is commonly delivered through a metered-dose inhaler (MDI) to treat asthma and other respiratory conditions. Proper inhaler technique is crucial for eﬀective delivery of the medication to the lungs.

Option (a) is incorrect because the client should actually tilt their head back slightly and breathe out fully before inhaling the medication.

Option (b) is incorrect because the client should take a slow, deep breath in while depressing the canister once.

Option (d) is incorrect because the client should hold their breath for 10 seconds after inhaling the medication to allow it to reach the lungs.

Therefore, the correct instruction for the nurse to include in the teaching is to instruct the client to close their mouth around the mouthpiece of the inhaler to ensure that the medication is delivered directly to the lungs.

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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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse eﬀect of the treatment?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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