A nurse is caring for a client who reports hearing voices that tell them to perform acts of self-harm. Which of the following actions should the nurse take first?
Initiate one-to-one observation for the client.
Turn on soft music to distract the client from hearing voices.
Ask the client what they are hearing.
Refer to the hallucination as if it were real.
The Correct Answer is C
Rationale:
A. Initiate one-to-one observation for the client: One‑to‑one observation is essential for safety when a client expresses risk for self‑harm, but the nurse must first assess the content of the hallucinations to determine the immediacy and severity of the risk. Understanding what the voices are saying guides the urgency of interventions and the level of monitoring required.
B. Turn on soft music to distract the client from hearing voices: Distraction techniques can help clients manage hallucinations, but they are not appropriate as an initial action when the client is reporting commands related to self‑harm. The priority is to gather critical assessment data before attempting coping strategies that may not address imminent danger.
C. Ask the client what they are hearing: Assessing the content, tone, and intent of the hallucinations is the first priority because command hallucinations can pose significant danger. Asking directly helps the nurse determine whether the client has an immediate plan or intent to act, which guides safety precautions and necessary interventions.
D. Refer to the hallucination as if it were real: Reinforcing hallucinations can worsen the client’s disorientation and increase distress. The nurse should maintain therapeutic boundaries by acknowledging the client’s experience without validating the hallucination, while also performing an immediate assessment of the risk of self‑harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Rationale:
A. Wash hands with an alcohol-based cleaner: Alcohol-based hand sanitizers are not effective against Clostridium difficile spores. Handwashing with soap and water is necessary to physically remove spores and reduce transmission.
B. Wear a gown when providing care: Contact precautions, including wearing a gown, are essential to prevent the spread of C. difficile through contaminated clothing and surfaces. Gowns help protect the nurse and other clients from infection.
C. Remove the thermometer from client's room for use on another client: Using equipment on multiple clients without proper disinfection can spread C. difficile. Disposable or dedicated equipment should be used, or the thermometer must be disinfected before reuse.
D. Wear an N95 respirator when providing care: C. difficile is transmitted via the fecal-oral route, not airborne. An N95 respirator is not required; standard surgical masks are sufficient if needed for droplet precautions.
E. Change gloves after contact with infectious material: Proper glove use and changing gloves after contact with fecal material or contaminated surfaces prevent cross-contamination and reduce the risk of spreading C. difficile to other clients or surfaces.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for correct choices
• Compartment syndrome: The child has a nondisplaced fracture of the radius and ulna, which can lead to swelling and increased pressure within the forearm compartments. Compartment syndrome is a serious complication that can compromise circulation and nerve function if not identified and treated promptly. Early recognition is critical to prevent permanent muscle and nerve damage.
• Paresthesia: The child reports mild tingling in the fingers, indicating early sensory nerve involvement. Paresthesia is a key early sign of neurovascular compromise in compartment syndrome. Monitoring for worsening tingling, numbness, or pain is essential for timely intervention, such as fasciotomy if needed.
Rationale for incorrect choices
• Deep vein thrombosis: DVT is uncommon in pediatric patients, especially in the absence of immobility, central lines, or hypercoagulable conditions. While fractures increase risk in adults, it is not the highest-priority risk in this 9-year-old child with an acute upper extremity fracture.
• Malunion: Malunion refers to healing of a fracture in an abnormal position. While possible, this risk develops over time and is not the immediate concern in the acute phase. Neurovascular compromise and compartment syndrome are more urgent.
• Type of fracture: While the fracture type (nondisplaced radius and ulna) informs management, it does not by itself represent the complication risk. The clinical symptoms of tingling are more directly indicative of acute neurovascular compromise.
• Ecchymosis: Bruising reflects local tissue trauma but is not a definitive indicator of compartment syndrome. Ecchymosis should be monitored but does not provide the highest-priority evidence of risk.
• Location of fracture: The midshaft location guides treatment, such as splinting, but the presence of paresthesia is more directly associated with risk for compartment syndrome. Location alone does not indicate imminent neurovascular compromise.
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