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 choice d. Wear a gown when assisting the client with personal hygiene. Choice A rationale: Removing personal protective equipment (PPE) after leaving the client’s room is incorrect. PPE should be removed before leaving the room to prevent the spread of MRSA to other areas. Choice B rationale: Ensuring that the negative air pressure is active for the client’s room is incorrect. Negative air pressure rooms are typically used for airborne infections, such as tuberculosis, not for MRSA, which is spread by contact. Choice C rationale: Restricting the client’s visitors is not necessary. Visitors should follow contact precautions, such as wearing gowns and gloves, but they do not need to be restricted. Choice D rationale: Wearing a gown when assisting the client with personal hygiene is correct. This helps prevent the spread of MRSA by protecting the nurse’s clothing and skin from contamination.

A. Muscle cramps B. Constipation C. Blurred vision D. Hypertension

Correct Answer is A

Explanation

The correct answer is A. Muscle cramps. Hyponatremia is a condition where sodium levels in the blood are lower than normal, which can cause water to move into body cells and make them swell. This can affect muscle cells and cause cramps, spasms or weakness. The other options are not typical signs of hyponatremia.

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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

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Correct Answer is A

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