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."
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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Related Questions
Correct Answer is A
Explanation
To calculate the percentage of weight loss, we can use the formula:
Percentage of weight loss = (Weight loss / Original weight) * 100
Given that the client lost 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb), we can substitute these values into the formula:
Percentage of weight loss = (6.8 kg / 90.7 kg) * 100 Percentage of weight loss = 0.0749 * 100 Percentage of weight loss = 7.49%
The percentage of weight loss is approximately 7.49%.
Since none of the provided answer options exactly match this calculated percentage, the closest option is:
So, the nurse should identify the weight loss as approximately 7.5%.
Correct Answer is C
Explanation
The correct answer is C.
Engage in low-impact aerobic exercises. Low-impact aerobic exercises, such as walking, swimming, or cycling, can help improve joint mobility, muscle strength, and cardiovascular health in clients with arthritis. They can also reduce pain and inflammation by increasing blood flow and oxygen delivery to the joints. The nurse should advise the client to avoid high-impact exercises, such as running or jumping, that can worsen joint damage and pain. The nurse should also recommend sleeping on a firm mattress that supports the spine and joints, applying heat to relax stiff muscles and joints, and using assistive devices or palms to push off from surfaces to avoid putting extra stress on the fingers.
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