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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Bradypnea: Respiratory depression is the most serious and potentially life-threatening adverse effect of morphine, especially after IV administration when onset is rapid. Bradypnea indicates a compromised airway and inadequate ventilation, making it the nurse’s priority for immediate assessment and intervention to prevent hypoxia and respiratory arrest.

B. Sedation: Sedation is a common effect of morphine and requires monitoring, but it is less immediately dangerous than respiratory depression. The nurse should assess the depth of sedation and level of consciousness while ensuring airway safety.

C. Constipation: Constipation is a common long-term side effect of opioids, but it is not an immediate threat to life. Preventive measures can be planned, but it does not take priority over acute respiratory compromise.

D. Euphoria: Euphoria may occur with opioid administration and is generally not harmful in the short term. While the nurse should monitor for behavioral changes or signs of misuse, it does not pose an immediate risk compared with respiratory depression.

A. Respite care B. Food stamps C. Medicaid D. Medicare Part A E. Adult day care

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

Explanation

Rationale:

A. Respite care: Respite care provides temporary relief for caregivers, but it does not directly assist clients with limited financial resources in obtaining home IV therapy or covering medical costs. This resource may be helpful later but is not a primary financial support option.

B. Food stamps: Supplemental Nutrition Assistance Program (SNAP), or food stamps, helps low-income clients access adequate nutrition. Proper nutrition is important for healing and overall health, making this a relevant resource for a client below the poverty level.

C. Medicaid: Medicaid provides health coverage for low-income individuals and can help cover costs associated with home IV therapy, medications, and other healthcare needs. It is an appropriate recommendation for a client who meets income eligibility criteria.

D. Medicare Part A: Medicare primarily covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services for clients over 65 or with certain disabilities. A young adult below the poverty level may not qualify, making this less appropriate for the scenario.

E. Adult day care: Adult day care provides socialization and supervision during the day, mainly for older adults or those with cognitive impairments. It does not address financial assistance or coverage for home IV therapy, so it is not a primary resource in this case.

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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?

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