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 B

Explanation

Choice A rationale:

Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.

Choice B rationale:

Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.

Choice C rationale:

Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.

Choice D rationale:

Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.

A. Shorten a reading activity when the child appears to become frustrated. B. Introduce some humor during interactions with the child. C. Redirect with physical activities when the child's disruptive behavior begins. D. Explain to the child the importance of picking up crayons when thrown on the floor. E. Place the child in a vest restraint when disruptive behavior occurs.

Correct Answer is ["A","B","C","D"]

Explanation

The correct answer is: A, B, C, D.

Choice A reason: Shortening a reading activity when the child appears to become frustrated can help prevent the child from becoming overwhelmed and acting out. This is a common strategy used in managing children with conduct disorders.

Choice B reason: Introducing humor during interactions with the child can help build rapport and make the child feel more comfortable. It can also serve as a positive distraction and reduce tension.

Choice C reason: Redirecting with physical activities when the child’s disruptive behavior begins can serve as a healthy outlet for the child’s energy and frustrations. Physical activities can also help improve the child’s mood and reduce disruptive behaviors.

Choice D reason: Explaining to the child the importance of picking up crayons when thrown on the floor can help teach the child responsibility and respect for their environment. This can also be a part of behavioral therapy where the child learns about consequences of their actions.

Choice E reason: Placing the child in a vest restraint when disruptive behavior occurs is not recommended. Using physical restraints can be traumatizing and should only be used as a last resort when the child’s behavior poses a risk to themselves or others. It’s always better to use de-escalation techniques and positive reinforcement to manage disruptive behavior.

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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 is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Correct Answer is B

Explanation

A nurse is caring for a school-age child who has a history of conduct disorder. Which of the following actions should the nurse take while caring for the child? (Select all that apply.).

Correct Answer is ["A","B","C","D"]

Explanation

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A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?

A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. The nurse recognizes that which of the following is an expected history associated with Wernicke-Korsakoff syndrome?

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