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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hyperactive bowel sounds refer to an increased intensity, frequency, and loudness of bowel sounds. They are typically described as loud, high-pitched, and occurring more frequently than normal. This can indicate increased bowel motility and may be associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction.
No sounds heard after listening for 3 to 5 minutes: This describes absent or hypoactive bowel sounds, where no sounds or very few sounds are heard. It can indicate decreased or absent bowel motility and may be seen in conditions such as ileus or peritonitis.
Sounds are soft and at a rate of 1/min: This describes normal or hypoactive bowel sounds, where the sounds are relatively quiet and occur at a slower rate (usually 5-34 sounds per minute). It may be observed in situations such as during sleep, after eating, or in certain conditions like constipation or paralytic ileus.
Indicates decreased motility: This is an inaccurate statement for hyperactive bowel sounds.
Hyperactive bowel sounds actually indicate increased motility, as mentioned earlier. Decreased motility would be associated with hypoactive or absent bowel sounds.
Correct Answer is A
Explanation
A nurse caring for a client who is 2 days postoperative following an above-the-knee amputation should encourage the client to use the overbed trapeze. This will promote independence and mobility by allowing the client to reposition themselves in bed and perform upper body exercises.
Maintaining abduction of the client's residual limb with a pillow can help prevent contractures, but it does not directly promote mobility.
Cautioning the client to avoid a prone position while in bed is appropriate to prevent pressure injuries and promote healing, but it also does not directly promote mobility.
Keeping a loose, absorbent dressing over the client's surgical site is important for infection control but does not promote mobility.
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