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.”

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A:

While this response is well-intentioned, it may not be the most therapeutic in this situation. It could be perceived as dismissive of the client's feelings and concerns. Clients with schizophrenia often have difficulty trusting others, and this response could reinforce the client's belief that they are being held against their will.

It's important to acknowledge the client's feelings and concerns, rather than simply stating that the healthcare team is there to help.

Choice B:

This response is the most therapeutic because it uses the technique of reflection. Reflection involves echoing back the client's feelings or thoughts, which can help them feel heard and understood. It can also encourage the client to elaborate on their concerns.

By reflecting the client's statement, the nurse validates their feelings and opens the door for further communication.

Choice C:

This response could be perceived as confrontational or challenging, which could further escalate the client's anxiety. It's generally more helpful to start with a more open-ended question or reflection.

Asking "why" questions can sometimes make people feel defensive or put on the spot.

Choice D:

While relaxation techniques can be helpful for some clients, this response is not appropriate in this situation. It minimizes the client's concerns and does not address their underlying feelings of fear and anxiety.

It's important to validate the client's feelings before suggesting coping strategies.

A. Sexual behaviors B. Frequency of hospitalizations C. Sodium level D. Hepatitis Viral Study (HAA) results

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

Explanation

Choice C rationale:

Sodium level is a critical electrolyte that plays a vital role in maintaining fluid balance, nerve and muscle function, and blood pressure. Naltrexone, one of the medications the patient is taking, has the potential to cause hyponatremia (low sodium levels) as a side effect. Hyponatremia can manifest with various symptoms, including headache, nausea, vomiting, confusion, seizures, and even coma in severe cases. Prompt recognition and management of hyponatremia are crucial to prevent serious complications.

Rationale for Immediate

Potential for Hyponatremia: Naltrexone, an opioid antagonist, can interfere with the body's ability to regulate sodium levels, leading to hyponatremia.

Serious Consequences of Hyponatremia: Low sodium levels can disrupt vital bodily functions, potentially causing neurological symptoms, seizures, and even coma.

Need for Prompt Intervention: Early detection and correction of hyponatremia are essential to prevent adverse outcomes.

Monitoring and Management: The nurse should assess the patient's sodium level, monitor for signs and symptoms of hyponatremia, and initiate appropriate interventions as needed, such as fluid restriction or electrolyte replacement.

Choice D rationale:

Hepatitis Viral Study (HAA) results are essential for determining the patient's hepatitis A status. Hepatitis A is a highly contagious liver infection that can cause significant illness. Fluoxetine, the other medication the patient is taking, can potentially cause liver damage in rare cases. Therefore, it's crucial to ensure that the patient does not have hepatitis A before initiating or continuing Fluoxetine therapy.

Rationale for Immediate

Potential Liver Injury: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has a rare but potential risk of hepatotoxicity (liver damage).

Hepatitis A Risk: Hepatitis A infection can further exacerbate liver injury, increasing the risk of complications.

Baseline Assessment: HAA results provide information about the patient's hepatitis A status, aiding in risk assessment and management decisions.

Monitoring and Precautions: If the patient tests positive for hepatitis A, the nurse should initiate appropriate precautions to prevent transmission and closely monitor liver function during Fluoxetine therapy.

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A nurse is caring for a client who is experiencing auditory hallucinations. What should the nurse say first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I’m being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?

Correct Answer is B

Explanation

Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning. The nurse has reviewed the client’s electronic health record. Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

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

Explanation

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A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?