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 B
Explanation
Tranylcypromine is a monoamine oxidase inhibitor (MAOI) medication used to treat depression. MAOIs inhibit the activity of the enzyme monoamine oxidase, which helps regulate the breakdown of certain neurotransmitters, including tyramine. Tyramine is typically broken down by monoamine oxidase, but when taking an MAOI, the enzyme's inhibition can lead to an excessive accumulation of tyramine in the body.
Tyramine-rich foods, such as aged cheeses, cured meats, and certain fermented or pickled foods, contain high levels of tyramine. Ingesting these foods while taking an MAOI can lead to a sudden release of stored norepinephrine, causing a hypertensive crisis.
Hypertension is a potentially serious adverse effect of MAOI therapy combined with tyramine-rich food ingestion. Symptoms of a hypertensive crisis can include severe headache, palpitations, chest pain, sweating, blurred vision, and in severe cases, it can lead to stroke or other cardiovascular complications.
Hematuria refers to the presence of blood in the urine and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Tinnitus refers to the perception of ringing or noise in the ears and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Hyperglycemia, or high blood sugar levels, is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion. However, it's important to note that tranylcypromine may interact with certain diabetes medications, so it's essential to consider the client's overall medical history and potential drug interactions.
Correct Answer is C
Explanation
During a seizure, the child's muscles may contract forcefully, which can lead to accidental biting of the tongue or inner cheek. Inspecting the child's mouth for any signs of injury, such as bleeding or lacerations, is important for assessing and addressing immediate needs.
Instead of placing the child in a supine position (flat on their back), it is recommended to position them on their side (recovery position) to help maintain an open airway and prevent aspiration in case of vomiting or secretions. This position also helps promote drainage of saliva or other fluids from the mouth.
Seizures can be frightening for both the child and their caregivers. Providing a calm and soothing environment, offering comfort, and reassuring the child and their family can help alleviate anxiety and promote a sense of safety.
Administering medication or offering fluids should be determined based on the healthcare provider's orders and individual circumstances. It is essential to consult with the healthcare team for specific instructions regarding medications and fluid management after a seizure episode.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today