A nurse is talking with a client who has 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?.
"What are the voices telling you to do?".
"Why do you think you are hearing the voices?".
"You need to understand that there are no voices.”.
"You need to tell the voices to leave you alone.”.
The Correct Answer is A
Choice A rationale:
Asking “What are the voices telling you to do?” shows empathy and concern without validating the hallucination.
Choice B rationale:
Asking “Why do you think you are hearing the voices?” might imply that the nurse is validating the hallucination.
Choice C rationale:
Telling the client “You need to understand that there are no voices.”. might make the client feel misunderstood.
Choice D rationale:
Telling the client “You need to tell the voices to leave you alone.”. is not recommended as it might validate the hallucination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Weight gain is not typically associated with acute mania in bipolar disorder.
Choice B rationale:
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
Choice C rationale:
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
Choice D rationale:
Dressing in all black is not a specific symptom of acute mania.
Correct Answer is D
Explanation
Choice A rationale:
Diarrhea is not a specific reason to stop lithium. However, severe diarrhea can affect lithium levels and should be reported to a healthcare provider.
Choice B rationale:
Lithium does not need to be taken on an empty stomach. It can be taken with or without food.
Choice C rationale:
A low-salt diet is not recommended while on lithium. In fact, a consistent, normal sodium intake is important because low sodium levels can cause lithium levels to become too high.
Choice D rationale:
Regular blood tests are necessary when taking lithium to ensure therapeutic levels and prevent toxicity. Weekly blood tests may be required during the first month of treatment.
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