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.

Iron absorption is inhibited by calcium, which is found in milk and dairy products. Therefore, the nurse should advise the client to avoid drinking milk with the iron supplement. The nurse should also encourage the client to consume foods rich in vitamin C, such as berries and citrus fruits, which can enhance iron absorption.

A. "I wouldn't worry about this right now. Let's focus on your chemotherapy." B. I will get you information about some head-covering options." C. "Let's discuss this when we have more time." D. "I can't imagine how difficult it would be to lose my hair."

Correct Answer is B

Explanation

Answer: B.I will get you information about some head-covering options." Explanation: This response shows empathy and respect for the client's concerns and provides information and support for coping with hair loss. The other responses are dismissive, evasive, or intrusive.

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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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