A nurse is conversing with a client diagnosed with schizophrenia.
Suddenly, the client expresses fear, stating, “I’m scared.
Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?
Why do you believe you are hearing voices?
What are the voices instructing you to do?
You need to comprehend that there are no voices.
Are the voices familiar to you?
The Correct Answer is B
Choice A rationale:
Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.
It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.
It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.
Choice B rationale:
Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.
This information can be used to develop a safety plan and to help the client manage their symptoms.
It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.
Choice C rationale:
Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.
It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.
It can also damage the therapeutic relationship between the nurse and the client.
Choice D rationale:
Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.
While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A rationale:
Incorrect. While patients typically do sleep for a period after ECT, the duration is usually shorter, around 30-60 minutes.
Providing inaccurate information about the length of sleep can lead to confusion and anxiety for the patient.
Evidence: Studies have shown that the average recovery time following ECT is around 30-60 minutes, with most patients feeling alert and oriented within that time frame. (Source: NIH.gov) Choice B rationale:
Incorrect. While ECT can be highly effective in treating depression, it is not considered a cure. It's important to manage expectations and emphasize that ECT is a treatment option that can significantly improve symptoms but may not guarantee a complete cure.
Evidence: Research indicates that ECT has a remission rate of approximately 50-70% in patients with severe depression, meaning that many patients experience a significant reduction or disappearance of symptoms. However, relapse rates can range from 30-50%, indicating that ongoing maintenance treatment is often necessary. (Source: American Psychiatric Association)
Choice C rationale:
Incorrect. Muscle relaxants, not seizure-preventing medications, are administered during ECT to protect the patient from injury during the induced seizure. It's crucial to clarify this distinction to avoid misunderstandings about the procedure's mechanism of action.
Evidence: Standard ECT protocols involve the use of a short-acting muscle relaxant, such as succinylcholine, to prevent muscle contractions during the seizure. This helps to minimize the risk of physical injury and ensure patient safety. (Source: Healthline.com)
Choice D rationale:
Correct. Temporary memory loss is a common side effect of ECT, and it's essential to inform patients about this potential issue to prepare them for the experience and address any concerns they may have.
Evidence: Studies have shown that approximately 40-50% of patients experience some degree of memory impairment following ECT, primarily affecting short-term memory of events occurring around the time of treatment. However, this memory loss is usually temporary and resolves within a few weeks or months for most patients. (Source: Studocu.com)
Correct Answer is A
Explanation
Choice A rationale:
I will contact my provider if I have difficulty urinating.
Chlorpromazine has anticholinergic effects, which can cause urinary retention. This means the medication can interfere with the normal function of the bladder, making it difficult to empty completely. Difficulty urinating can lead to bladder distention, urinary tract infections, and even kidney damage if left untreated.
It's crucial for the client to recognize this potential side effect and seek medical attention promptly if it occurs. Early intervention can help prevent complications and ensure proper bladder management.
By understanding this potential side effect and the importance of seeking help, the client demonstrates a grasp of the teaching provided.
Choice B rationale:
I might notice an increased frequency of my menstrual cycle.
Chlorpromazine does not typically affect menstrual frequency. While some antipsychotic medications can cause menstrual irregularities, chlorpromazine is not commonly associated with this effect.
If a client experiences changes in their menstrual cycle while taking chlorpromazine, it's important to discuss it with their healthcare provider to rule out other potential causes.
Choice C rationale:
These medications might cause breast tissue to atrophy.
Chlorpromazine is not known to cause breast atrophy. Breast atrophy, or shrinkage of breast tissue, can occur due to hormonal changes, aging, or certain medical conditions.
However, it's not a common side effect of chlorpromazine.
Choice D rationale:
I am at a decreased risk for infection while taking these medications.
Chlorpromazine does not decrease the risk of infection. In fact, it may slightly increase the risk of infection due to its potential to suppress the immune system.
It's essential for clients taking chlorpromazine to practice good hygiene and infection prevention measures to protect themselves from illness.
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