A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions should the nurse take?

Administer a dose of fluoxetine to the client.

Avoid making eye contact with the client.

Request the client to lie down in a quiet room.

Encourage the client to listen to music.

Answer and Explanation

The Correct Answer is D

A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.

B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.

C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.

D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Instruct the client to flex their head in a chin-down position: Flexing the head forward helps close the airway and direct food toward the esophagus, reducing the risk of aspiration. This maneuver is a standard safety technique for clients with dysphagia during swallowing.

B. Place the food on the weaker side of the client's mouth: Food should be placed on the stronger side of the mouth to facilitate effective chewing and swallowing. Placing food on the weaker side increases the risk of aspiration and choking.

C. Thin the food to a liquid consistency prior to feeding: Thinner liquids are more difficult for clients with dysphagia to control and swallow safely. Thickened liquids are recommended to slow flow and improve swallow safety.

D. Place the client in a semi-Fowler's position while eating: While upright positioning is important, semi-Fowler’s (30–45 degrees) may not be sufficient. A full upright position (90 degrees) is preferred to optimize swallowing and reduce aspiration risk.

A. Thrombocytopenia B. Hypothermia C. Maternal diabetes D. Prematurity E. Anemia

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

Explanation

Rationale:

A. Thrombocytopenia: Low platelet count is not a recognized risk factor for neonatal hypoglycemia. While it may indicate other hematologic concerns, it does not directly affect the infant’s glucose regulation.

B. Hypothermia: Hypothermia increases metabolic demand and glucose consumption in newborns, making them more susceptible to hypoglycemia. Maintaining neutral thermal environment is crucial to reduce this risk.

C. Maternal diabetes: Infants of mothers with diabetes are at increased risk for hypoglycemia due to fetal hyperinsulinemia. After birth, the high insulin levels can cause a rapid drop in blood glucose.

D. Prematurity: Premature infants have limited glycogen stores, immature liver function, and impaired gluconeogenesis, all of which increase the risk of hypoglycemia. Monitoring and early feeding are essential.

E. Anemia: While anemia can affect oxygen delivery, it is not a direct risk factor for hypoglycemia in the newborn. It may complicate overall neonatal status but does not independently cause low blood glucose.

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A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take when feeding the client?

Correct Answer is A

Explanation

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

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

Explanation

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