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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 A

Explanation

Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.

A. The importance of medication adherence after the resolution of acute psychosis when taking an antipsychotic. B. The importance of limiting fluid intake when taking an antipsychotic. C. The importance of routine red blood cell count laboratory work when taking an antipsychotic. D. The importance of avoiding foods that contain tyramine when taking an antipsychotic.

Correct Answer is A

Explanation

Choice A rationale:

Adherence to medication, especially after the resolution of acute psychosis, is crucial when taking an antipsychotic like clozapine. This is because discontinuation can lead to a relapse of symptoms.

Choice B rationale:

There’s no specific need to limit fluid intake when taking an antipsychotic.

Choice C rationale:

While routine blood cell count laboratory work is important, it’s not specific to red blood cells but rather to monitor for agranulocytosis, a potential side effect of clozapine.

Choice D rationale:

Avoiding foods that contain tyramine is typically associated with monoamine oxidase inhibitors, not antipsychotics like clozapine.

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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 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?.

Correct Answer is A

Explanation

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client?.

Correct Answer is A

Explanation

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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?.