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 B
Explanation
Choice A reason:
At the hip region is incorrect because it does not specify any clinical manifestation indicative of scoliosis.
Choice B reason
Uneven shoulder and pelvic heights are the correct position. Scoliosis is a condition characterized by an abnormal lateral curvature of the spine, often causing the spine to appear as an "S" or "C" shape when viewed from the back. When performing scoliosis screenings, the school nurse should look for signs that may indicate scoliosis, such as uneven shoulder and pelvic heights.
Choice C reason:
United tinge of moben of the hips is incorrect because it does not describe a known clinical manifestation of scoliosis and appears to contain typographical errors.
Choice D reason:
Exaggerated curvature of the sacrum is incorrect because it is not a characteristic clinical manifestation of scoliosis. The curvature of the sacrum is normal and not related to scoliosis.
Correct Answer is D
Explanation
The correct answer is D. Muscle pain is a sign of rhabdomyolysis, a rare but serious condition that can occur with statin use and can lead to kidney failure. The nurse should instruct the client to report any muscle pain, weakness, or tenderness to the provider immediately.
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