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 A

Explanation

The correct answer is A. The nurse should apply pressure to the lacrimal punctum, which is located at the inner corner of each eye, after administering eye drops to prevent systemic absorption of the medication and reduce side effects. The nurse should position the child supine or sitting with their head tilted back slightly before administering eye drops, as this allows for easier instillation and prevents spillage of medication. The nurse does not need to flush the eye with normal saline solution before administering eye drops, unless there is debris or discharge in the eye that needs to be removed. The nurse should wipe from the inner to the outer canthus after administering eye drops, as this prevents contamination of the eye and reduces the risk of infection.

A. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface. B. Open the side flap of the sterile kit, allowing it to lie flat on the work surface. C. Open the outermost flap of the sterile kit away from the nurse's body D. Apply sterile gloves.

Correct Answer is C

Explanation

The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.

Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of

the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.

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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

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