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 A
Explanation
Choice A rationale:
Weight gain is a common side effect of risperidone. Antipsychotic medications like risperidone often lead to weight gain.
Choice B rationale:
Bradycardia is not typically associated with risperidone. Risperidone can cause mild heart rate changes, but significant bradycardia is not common.
Choice C rationale:
Nightmares are not a typical side effect of risperidone. Sleep disturbances can occur, but they are not the most common side effect.
Choice D rationale:
Dependent edema is not a common side effect of risperidone.
Correct Answer is C
Explanation
Choice A rationale:
A lithium level of 1.8 mEq/L is above the therapeutic level for initial treatment (0.8 to 1.4 mEq/L)3.
Choice B rationale:
A lithium level of 1.8 mEq/L is above, not below, the therapeutic treatment level.
Choice C rationale:
A lithium level of 1.8 mEq/L is at the toxic level. A blood lithium level greater than 1.5 mEq/L indicates toxicity.
Choice D rationale:
A lithium level of 1.8 mEq/L is not within the maintenance treatment level (0.4 to 1.3 mEq/L)3.
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