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 A
Explanation
Rationale:
A. Provide the client with a stool softener: Clients with thrombocytopenia are at increased risk for bleeding, including gastrointestinal bleeding. Hard stools can cause straining during defecation, which may lead to rectal bleeding. Administering a stool softener helps prevent constipation and reduces the risk of bleeding from the gastrointestinal tract.
B. Remove fresh flowers from the client's room: This intervention is appropriate for clients who are immunocompromised to prevent infection, but it is not specifically necessary for thrombocytopenia unless the client also has neutropenia. The main concern in thrombocytopenia is bleeding, not infection.
C. Avoid serving the client raw vegetables: While raw vegetables may carry a risk of infection, thrombocytopenia alone does not require dietary restrictions for raw vegetables. Safe food handling is important, but preventing bleeding is the primary focus of care.
D. Encourage the client to floss daily: Flossing can increase the risk of gum bleeding in clients with thrombocytopenia. Oral hygiene should be maintained gently with soft-bristled toothbrushes, but daily flossing is not recommended because it may cause unnecessary bleeding.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices
- Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
- Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.
Rationale for Incorrect Choices
- Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
- Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
- Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.
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