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
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Pursed-lip breathing exercises help to reduce dyspnea and improve oxygenation in clients who have COPD.
Correct Answer is A
Explanation
The correct answer is A. Interlace the fingers while rubbing hands together. This is one of the steps of performing a surgical hand scrub, which is an antiseptic surgical scrub or antiseptic hand rub that is performed prior to donning surgical attire. Interlacing the fingers helps to remove microorganisms from the spaces between the fingers and under the nails.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today