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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 B

Explanation

Choice A rationale:

Asking why the client feels they will never get better might come across as dismissive or confrontational.

Choice B rationale:

This response acknowledges the client’s feelings and offers a supportive approach to managing the symptoms of somatic symptom disorder. This disorder is characterized by a significant focus on physical symptoms that cause major distress and/or problems functioning. The main treatment is psychotherapy, and medication might be given in some cases.

Choice C rationale:

Focusing only on the physical symptoms might not address the emotional distress that the client is experiencing.

Choice D rationale:

While it’s important to offer hope, this response might come across as dismissive of the client’s current feelings.

A. A client who has a BUN of 22 mg/dL. B. A client who has a serum potassium of 3.3 mEq/L. C. A client who has a hematocrit of 55%. D. A client who has a WBC of 2,900 cells/mm².

Correct Answer is D

Explanation

Choice A rationale:

A BUN of 22 mg/dL is slightly elevated but not a contraindication for clozapine.

Choice B rationale:

A serum potassium of 3.3 mEq/L is slightly low but not a contraindication for clozapine.

Choice C rationale:

A hematocrit of 55% is high but not a contraindication for clozapine.

Choice D rationale:

A WBC of 2,900 cells/mm² is low and can indicate agranulocytosis, a potentially life-threatening condition. Clozapine should be discontinued.

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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 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?

Correct Answer is B

Explanation

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

Correct Answer is D

Explanation

A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.).

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A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

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?.

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?.