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 C
Explanation
Rationale:
A. A client who has alcoholic pancreatitis: Alcoholic pancreatitis does not pose a risk of teratogenicity or infectious transmission to a pregnant nurse. Standard precautions are sufficient, making this assignment safe for a pregnant nurse.
B. A client who has latent tuberculosis: Latent TB is not contagious, as the bacteria are inactive and the client cannot transmit the infection. A pregnant nurse can safely care for this client with standard precautions without increased risk.
C. A client who is recovering from shingles: Shingles (herpes zoster) is caused by reactivation of the varicella-zoster virus and can be transmitted via direct contact with lesions. Pregnant nurses who have not had chickenpox or the varicella vaccine are at risk for serious complications, so this client should be assigned to a non-pregnant nurse.
D. A client who has HIV: HIV is transmitted through blood and body fluids, and standard precautions effectively protect healthcare workers. There is no contraindication for a pregnant nurse to care for a client with HIV using proper infection control measures.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. A client who moved to an apartment located on higher ground than her previous home: Relocating to a safer area demonstrates adaptive coping and proactive problem-solving. It does not indicate symptoms of posttraumatic stress disorder (PTSD) and does not require a referral for mental health assessment.
B. A client who has frequent nightmares about the hurricane: Recurrent intrusive thoughts or nightmares about a traumatic event are hallmark symptoms of PTSD. This client should be referred for further evaluation and possible treatment.
C. A client who expresses a realization that life will not return to the way it was before the hurricane: Accepting permanent changes after a disaster reflects normal adjustment and resilience. This insight alone does not suggest PTSD.
D. A client who describes feeling disconnected from those around him following the hurricane: Emotional numbing or detachment from others is a common PTSD symptom. This client should be referred for assessment to address potential social and emotional impairments.
E. A client who describes having persistent feelings of anger about the hurricane: Persistent irritability or anger is another symptom associated with PTSD. Referral is appropriate to evaluate for underlying trauma-related disorder and provide supportive interventions.
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