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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
Correct Answer is A
Explanation
A. Neonatal Infant Pain Scale (NIPS): The NIPS is a widely used and validated pain assessment tool specifically designed for newborns, including full-term infants like the 38-week gestation newborn in this case. It evaluates behavioral indicators such as facial expressions, crying, arm and leg movement, and physiological indicators like breathing patterns.
B. FACES pain rating scaleis designed for older children who can self-report pain by selecting a facial expression corresponding to their level of discomfort. It is not suitable for newborns who cannot self-report their pain.
C. Premature Infant Pain Profile (PIPP):The PIPP is specifically designed for preterm infants (less than 37 weeks of gestation) and assesses pain based on behavioral and physiological indicators.
D. Visual Analog Scale (VAS): The VAS requires a client to self-report their pain by indicating a point along a continuum, which is not appropriate for newborns.
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