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","C"]

Explanation

Turn cellular phones to silent mode: In an active shooter situation, it is crucial to maintain silence to avoid drawing attention to your location. Switching cellular phones to silent mode helps ensure that ringtones or notifications do not alert the shooter to your presence.

Wave hands to attract the attention of law enforcement: When law enforcement or emergency personnel arrive at the scene, it is essential to signal to them that you are not a threat and that you require assistance. This can be done by putting hands up, keeping them visible, and following any instructions provided by law enforcement.

Move wounded clients to a safe area before finding shelter: It is important to prioritize the safety of individuals involved in an active shooter situation. However, moving wounded clients should be done only if it can be done quickly and without putting oneself or others at risk. The primary goal is to seek safety and follow established protocols, such as "run, hide, fight" principles, rather than focusing on moving injured individuals during an ongoing threat.

Attempt to bargain with the shooter: Bargaining or negotiating with an active shooter is strongly discouraged. It is important to remember that the primary goal in an active shooter situation is to ensure personal safety and the safety of others. Engaging with the shooter may escalate the situation or put oneself and others at greater risk.

The in-service should focus on providing staff members with practical guidance on how to respond to an active shooter situation, emphasizing the importance of following established protocols, staying calm, and seeking safety. Additionally, the in-service should include training on recognizing and reporting suspicious behavior, as prevention and early intervention can play a crucial role in mitigating such incidents.

A. Incident report B. Nursing care plan C. Controlled substance inventory record D. Provider's progress notes

Correct Answer is A

Explanation

a. Incident report.

Whenever a medication error occurs, it should be documented in an incident report. The purpose of the incident report is to document the details of the event, including what happened, why it happened, and what was done to prevent it from happening again. Incident reports are not part of the client's medical record and are not used for disciplinary action. They are used for quality improvement and risk management purposes.

The nursing care plan is a document that outlines the client's nursing care needs and interventions. It is not the appropriate place to document a medication error.

The controlled substance inventory record is used to document the administration and dispensing of controlled substances. It is not the appropriate place to document a medication error.

The provider's progress notes document the provider's assessment, diagnosis, and treatment plan for the client. They are not the appropriate place to document a medication error.

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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 assisting with planning an in-service for staff members about active shooter protocols. Which of the following information should the nurse recommend including?

Correct Answer is ["B","C"]

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?

Correct Answer is A

Explanation

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