A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

"You need to tell the voices to leave you alone.”

"You need to understand that there are no voices.”

"What are the voices telling you to do?”

"Why do you think you are hearing the voices?”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

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Correct Answer is C

Explanation

Choice A rationale:

While wanting to go home to be with loved ones can be a sign of distress, it doesn't necessarily indicate an immediate risk of suicide. Many individuals express a desire to be with family when feeling down, and this statement alone is not a definitive indicator of suicide risk.

Choice B rationale:

Engaging in social activities like playing basketball with others is generally a positive sign, as it indicates some level of interaction and engagement. This choice is less likely to indicate an immediate suicide risk.

Choice C rationale:

The client demonstrating increased impulsive behaviors is a concerning sign. Rapid and impulsive actions can potentially lead to self-harm or dangerous situations. Increased impulsivity can indicate a lack of consideration for consequences, which may elevate the risk of suicidal behaviors.

Choice D rationale:

Identifying with problems expressed by other clients is not a specific indicator of suicide risk. While it may suggest empathy and shared experiences, it doesn't directly address the immediate risk factors related to the client's bipolar disorder.

A. "I pray when I begin to breathe fast.” B. "I journal when I find it difficult to talk.” C. "I fix myself a pot of coffee when I get anxious.” D. "I exercise when my neck is tense.”

Correct Answer is C

Explanation

Choice A rationale:

Praying and using relaxation techniques when experiencing rapid breathing are effective stress management strategies. These techniques help manage the body's stress response and promote relaxation.

Choice B rationale:

Journaling is a constructive way to manage stress, especially when verbal expression is difficult. It allows individuals to reflect on their thoughts and emotions, leading to a sense of relief.

Choice C rationale:

"Fixing a pot of coffee" when anxious is the least effective technique mentioned. Consuming large amounts of caffeine can exacerbate anxiety symptoms by increasing heart rate and contributing to a sense of restlessness and nervousness.

Choice D rationale:

Engaging in physical exercise when experiencing tension in the neck is a productive strategy. Exercise promotes the release of endorphins, which are natural mood lifters and stress reducers.

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A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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