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?”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Tachycardia.
Choice A rationale:
Metrorrhagia (Choice A) refers to irregular or excessive uterine bleeding between menstrual periods. While anorexia nervosa can disrupt menstrual cycles, causing amenorrhea, metrorrhagia is not a common associated finding.
Choice B rationale:
Tachycardia (Choice B), or an abnormally fast heart rate, is a hallmark of anorexia nervosa. The severe calorie restriction and electrolyte imbalances associated with anorexia can lead to cardiac complications, including rapid heart rate, as the body tries to compensate for the lack of nutrients.
Choice C rationale:
Hyperkalemia (Choice C), which is elevated levels of potassium in the blood, is not a typical finding in anorexia nervosa. Electrolyte imbalances in anorexia more commonly involve decreased potassium levels (hypokalemia) due to inadequate intake and excessive purging.
Choice D rationale:
Constipation (Choice D) is a possible consequence of anorexia nervosa. Reduced food intake can lead to decreased bowel movements and constipation. However, tachycardia is a more specific and significant finding associated with anorexia nervosa.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Misplacing car keys is a common occurrence in many people's lives and is not necessarily indicative of Alzheimer's disease. It can happen to anyone due to various factors like stress or distraction.
Choice B rationale:
Difficulty performing familiar tasks is a potential early warning sign of Alzheimer's disease. This can include tasks that the person previously did with ease, such as cooking or dressing themselves. Alzheimer's disease affects cognitive abilities, including the ability to perform familiar tasks.
Choice C rationale:
Losing sense of time is another potential early warning sign of Alzheimer's disease. People with Alzheimer's may lose track of days or seasons, as the disease impacts their sense of time and memory.
Choice D rationale:
Problems with performing basic calculations can be a sign of cognitive decline, but it is not one of the primary early warning signs of Alzheimer's disease. This choice is less specific to Alzheimer's and could be related to other cognitive disorders as well.
Choice E rationale:
Becoming lost in a usually familiar environment is a significant early warning sign of Alzheimer's disease. Individuals with Alzheimer's may become disoriented even in places they know well, leading to confusion and anxiety. This is a result of the disease affecting their spatial memory and navigation skills.
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