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 F
Explanation
Choice A rationale:
Instructing the client to avoid foods with tyramine is not relevant in this case. Tyramine is associated with certain antidepressants known as MAOIs, but the client is taking Fluoxetine, which is an SSRI2.
Choice B rationale:
Applying wrist restraints might be necessary in extreme situations to ensure the client’s safety, but it should be a last resort and not the first response to self-harm.
Choice C rationale:
Offering sympathy and attention to maladaptive behavior could reinforce negative behaviors and is not recommended.
Choice D rationale:
Encouraging the client to talk about feelings prior to maladaptive behavior can be beneficial. It can help the client develop healthier coping mechanisms.
Choice E rationale:
Maintaining the same staff members caring for the client can provide consistency and stability, which can be beneficial for individuals with Borderline Personality Disorder.
Choice F rationale:
Initiating suicide precautions is crucial in this situation. The client has a history of suicidal ideation and is exhibiting self-harming behavior.
Choice G rationale:
Offering the client opportunities for physical exercise can be beneficial as it can help manage stress and improve mood.
Choice H rationale:
Exploring feelings of abandonment with the client can be beneficial. It can help the client process these feelings in a healthier way.
Correct Answer is C
Explanation
Choice A rationale:
Group discussions about local elections can be stimulating and may exacerbate the client’s manic symptoms.
Choice B rationale:
Watching a video with a group in the day room may not provide enough engagement for a client in a manic phase.
Choice C rationale:
Walking with the nurse in the courtyard provides physical activity and one-on-one interaction, which can help manage energy levels and provide a calming influence.
Choice D rationale:
Participating in a basketball game in the gym could overstimulate the client and potentially lead to injury.
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