A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?
“I know you hear the voices, but I do not.”
“How often do you hear the voices?”
“What are the voices telling you?”
“The voices are part of your illness.”
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.
Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.
Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.
Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Telling the client to work hard to stay on the schedule does not address the underlying reasons for the client's difficulty in following a medication regimen and may come off as dismissive.
Choice B rationale: Saying not to worry about the past does not acknowledge the client's concerns and may not provide practical assistance for future adherence.
Choice C rationale: Offering reassurance without addressing the client's past challenges does not provide a concrete plan for improving adherence.
Choice D rationale: Asking the client why they find it difficult to take medications opens a dialogue that allows the nurse to understand the client's specific barriers and to provide tailored strategies to improve adherence. This response is empathetic and solution-focused.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.
Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.
Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.
Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.
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