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 C

Explanation

Choice A reason:

Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.

Choice B reason:

Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.

Choice C reason:

Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.

Choice D reason:

Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.

Choice E reason:

Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.

A. Have the child take a tub bath each morning B. Apply splints to the child's extremities during the day. C. Encourage the child to take naps during the day. D. Keep the child on bedrest as long as pain persists.

Correct Answer is A

Explanation

Correct answer:

A. Have the child take a tub bath each morning: Warm tub baths are recommended for children with juvenile idiopathic arthritis (JIA) as they help to relieve joint stiffness and pain, especially in the morning. The warm water can soothe the joints, making movement easier and reducing discomfort throughout the day.

Why the other options are less appropriate:

B. Apply splints to the child's extremities during the day: While splints may be used in JIA, they are typically applied during the night (resting splints) to maintain joint position and prevent contractures. Daytime use of splints (working splints) may be considered in certain situations, but generally, children are encouraged to be as active as possible during the day to maintain joint mobility.

C. Encourage the child to take naps during the day: While rest is important, encouraging too much rest during the day may contribute to joint stiffness. Regular activity helps maintain joint function and mobility, which is essential in managing JIA.Frequent daytime naps also interfere with the child's quality of sleep.

D. Keep the child on bedrest as long as pain persists: Prolonged bedrest is not recommended for children with JIA. It can lead to muscle atrophy, increased stiffness, and reduced joint mobility. Instead, the focus should be on maintaining activity within the child's pain tolerance and using pain management strategies.

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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 assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?

Correct Answer is A

Explanation

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