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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Rationale:

• Difficulty walking: Bone injury limits weight-bearing ability and causes alterations in gait. Localized pain and instability can make ambulation difficult. Clients often compensate with limping to avoid pressure on the injured limb. In DVT, A clot in the deep veins causes swelling and discomfort, making ambulation painful. The heaviness and fullness in the limb interfere with normal gait. Clients may develop a limp due to localized tenderness.

• Pain: A fracture typically produces sharp, localized pain that worsens with movement. Tissue disruption and swelling contribute to discomfort. The pain limits limb use and is often immediate after injury. DVT often causes aching or cramping pain in the affected limb, especially with walking. Venous congestion and inflammation contribute to tenderness. Pain increases when the calf is compressed or when standing.

• Limb heaviness: Venous obstruction causes blood pooling, producing a heavy and tight sensation. This finding reflects impaired venous return, especially when swelling is also present. It is common in unilateral DVT. A fracture typically causes sharp, localized pain rather than diffuse heaviness. Heaviness is more strongly associated with venous congestion.

• Fever: Low-grade fever may occur due to inflammatory response around the thrombus. Cytokine release produces systemic symptoms during clot formation. It can accompany swelling, warmth, and redness. A simple fracture does not generally cause systemic fever unless infection develops. Fever is more indicative of inflammatory or infectious conditions.

• Edema: Venous blockage leads to unilateral swelling due to trapped fluid and elevated venous pressure. The affected limb becomes warm, enlarged, and firm. This is a hallmark finding in deep vein thrombosis. While swelling may occur after a fracture, the client’s presentation shows significant unilateral edema matching venous obstruction.

A. Respiratory rate B. Pain level C. Blood pressure D. LDL E. Weight F. Hemoglobin A1c

Correct Answer is ["A","C","D","E","F"]

Explanation

Rationale:

A. Respiratory rate: The client’s respiratory rate decreased from 20/min to 18/min, indicating improved cardiopulmonary function and reduced physiological stress, which reflects overall improvement in health status.

B. Pain level: The client’s pain level remains at 0/10 both at baseline and follow-up, showing no change. Pain was not a concern initially, so this does not indicate improvement.

C. Blood pressure: Blood pressure decreased from 164/92 mm Hg to 138/84 mm Hg, demonstrating better hypertension management through lifestyle modifications and/or medications, indicating cardiovascular improvement.

D. LDL: LDL cholesterol improved significantly from 220 mg/dL to 90 mg/dL, reflecting effective hyperlipidemia management and reduced risk for cardiovascular disease.

E. Weight: The client’s weight decreased from 88.6 kg to 83.2 kg, reducing BMI from 30.5 to 28.7. This weight loss indicates successful lifestyle modifications and improvement in overall metabolic health.

F. Hemoglobin A1c: HbA1c decreased from 7% to 6%, showing improved long-term glycemic control and reduced risk for diabetes-related complications, reflecting an overall improvement in metabolic health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

The nurse has reviewed the Nurses' Notes, Vital Signs, and Laboratory Results from 3 months ago. Exhibits The nurse is reviewing the client's plan of care. Which of the following findings indicate the client's condition has improved? Select all that apply.

Correct Answer is ["A","C","D","E","F"]

Explanation

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