A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

"Let's take a walk outside to see if the voices you are hearing will stop."

"Can you listen to me instead of the voices you are hearing?"

"Are the voices you are hearing telling you to hurt yourself or someone else?"

"I know that the voices are real to you, but I do not hear them."

Answer and Explanation

The Correct Answer is C

The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.

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Correct Answer is D

Explanation

The correct answer is D. The parent should apply pressure with gauze if they see bleeding from the circumcision site, as this can indicate a complication such as infection or dislodgement of the plastic ring. The other statements are incorrect because they can interfere with the healing process or cause harm to the infant. Applying antibiotic ointment can cause irritation or allergic reaction, applying a snug diaper can increase pressure and friction on the penis, and wiping away yellow crusts can remove healthy tissue or cause bleeding .

A. A nurse discovers that a client's family member has administered a PCA dose. B. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. C. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. D. A nurse observes a client vomiting after receiving an oral pain medication. E. None F. None

Correct Answer is B

Explanation

A.While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.

B.An error in fluid administration by an IV pump, especially when it involves delivering twice the prescribed amount, is a medication error that could have serious consequences, such as fluid overload or electrolyte imbalances. An incident report must be filed to document the event and investigate what went wrong with the equipment.

C.Removing wrist restraints one at a time, particularly when the client is calm, follows safe practice to prevent injury. This situation does not represent an error, violation, or adverse event, and does not require an incident report. Restraints should always be removed cautiously and gradually to ensure client safety.

D.A client vomiting after receiving an oral pain medication could be an adverse drug reaction. While this is important to document in the patient’s medical record, it may not always require an incident report unless it leads to further complications or indicates a medication error.

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A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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