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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.”.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

While it’s interesting to consider why people isolate themselves, this statement does not provide a clear explanation for the behavior.

Choice B rationale:

Being an introvert or extrovert doesn’t necessarily correlate with the onset of schizophrenia symptoms.

Choice C rationale:

Before symptoms of schizophrenia begin, people often isolate themselves. This is known as the prodromal phase of schizophrenia.

Choice D rationale:

Avoiding friends to hear voices more clearly is not a typical behavior associated with the onset of schizophrenia.

A. GI discomfort and poor coordination. B. Lip smacking and tongue thrusting. C. Blurred vision and jerking motor movements. D. Fever and fluctuating blood pressure.

Correct Answer is A

Explanation

Choice A rationale:

A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.

Choice B rationale:

Lip smacking and tongue thrusting are not typically associated with lithium toxicity.

Choice C rationale:

While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.

Choice D rationale:

Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, "My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?" Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.

Correct Answer is A

Explanation

A nurse is teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse, "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better.”. Which of the following responses is the most therapeutic?

A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation. Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?

A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?.

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.).

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

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?.