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","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.
Correct Answer is C
Explanation
Rationale:
A. Change a dressing on an implanted central venous access device: This is a sterile procedure that requires assessment skills and knowledge of infection control. It must be performed by a licensed nurse, not an assistive personnel (AP).
B. Suction a new tracheostomy: Suctioning a new tracheostomy is a high-risk procedure requiring specialized knowledge to prevent hypoxia or trauma. Only a licensed nurse should perform this intervention.
C. Perform postmortem care: Postmortem care is within the scope of practice for an AP. It involves cleansing, positioning, and preparing the body for the family or mortuary, and does not require advanced clinical judgment or sterile technique.
D. Remove an NG tube: Removal of a nasogastric tube requires assessment and understanding of client tolerance and potential complications, which are responsibilities of a licensed nurse. It is not appropriate to delegate this task to an AP.
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