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 C

Explanation

The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart.

This can help alleviate dyspnea and improve oxygenation in clients with heart failure.

A. A client who has a spinal cord injury B. A client who has acute appendicitis C. A client who has a urinary tract infection D. A client who has a torn rotator cuff

Correct Answer is A

Explanation

The correct answer is A. A client who has a spinal cord injury requires an interprofessional approach to care that involves multiple disciplines such as physical therapy, occupational therapy, social work, and rehabilitation nursing. The other clients have less complex needs that can be managed by one or two disciplines.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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