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 C

Explanation

Explanation:

Sponge baths are recommended until the umbilical cord stump falls oﬀ, which typically occurs within the first two weeks of life. After that, the baby can be immersed in water for a regular bath.

Using talcum powder is not recommended as it can be harmful to the baby's respiratory system if inhaled. Mild, pH-balanced soap should be used instead of alkaline soap to avoid irritating the baby's delicate skin.

The bathwater temperature should be around 98 degrees Fahrenheit and not hoter than 100 degrees Fahrenheit to prevent burns.

A. Give the client a barbiturate medication at bedtime. B. Encourage the client to take frequent walks during the day. C. Allow the client to nap for at least 1 hr during the day. D. Put a simple lock on the client's bedroom door.

Correct Answer is B

Explanation

As a nurse, the intervention that should be recommended is encouraging the client to take frequent walks during the day. This will help the client expend some energy and reduce the restlessness that could be causing the sleep disturbance at night.

The other options are not recommended because barbiturate medications can cause excessive sedation, allowing the client to nap for at least 1 hour during the day can interfere with their ability to sleep at night, and putting a lock on the client's door can be a safety risk in case of an emergency.

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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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