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?

"Why do you think you are hearing the voices?

"What are the voices telling you to do?"

you need to tell the voices to leave you alone."

"You need to understand that there are no voices.

Answer and Explanation

The Correct Answer is B

A. "Why do you think you are hearing the voices?" This question may come across as confrontational and might make the client defensive. It's better to focus on the content of the hallucinations rather than questioning the client's perception.

B. "What are the voices telling you to do?"
This response is appropriate because it acknowledges the client's experience, shows empathy, and encourages the client to express their thoughts and feelings. It is important to gather more information about the content of the hallucinations and delusions to understand the client's perception of reality.

C. "You need to tell the voices to leave you alone." This response oversimplifies the experience of hallucinations and may not be helpful. Telling the client to dismiss the voices is unlikely to be effective and may lead to frustration.

D. "You need to understand that there are no voices." Denying the client's experience is not therapeutic. It's essential to validate the client's feelings and explore their subjective experience rather than dismissing it outright.

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Correct Answer is D

Explanation

A. Diazepam (Valium) is a benzodiazepine used for anxiety. While benzodiazepines can cause sedation and might carry a risk of dependence, they are not typically associated with an increased risk of suicidal ideation compared to antidepressants.

B. Diphenhydramine (Benadryl) is an antihistamine that might cause drowsiness and sedation. It's not primarily used for anxiety disorders, and it's less associated with increased suicidal risk compared to antidepressants.

C. Propranolol (Inderal) is a beta-blocker used for treating conditions like hypertension and anxiety disorders. It's not typically associated with an increased risk of suicide compared to antidepressants.

D. A client who has obsessive-compulsive disorder and takes fluoxetine (Prozac).
Fluoxetine (Prozac) is an antidepressant that belongs to the class of medications called selective serotonin reuptake inhibitors (SSRIs). While it's effective for treating OCD, when initiating or adjusting the dosage of an antidepressant like fluoxetine, there can be an increased risk of suicidal ideation or behavior, especially in younger individuals. This risk is particularly prevalent in the initial weeks of treatment or when there are dosage changes.

A. "Everyone has trouble sleeping at times." B. "Why do you think you are so anxious?" C. Have you talked to your provider about this yet? D. It sounds like you're having a difficult time.

Correct Answer is C

Explanation

A. "Everyone has trouble sleeping at times" minimizes the client's concerns and may not address the underlying issues contributing to their anxiety.

B. "Why do you think you are so anxious?" might come across as judgmental or confrontational, and it may not create a supportive environment for the client to open up about their feelings.

C. "Have you talked to your provider about this yet?"
This response encourages the client to seek professional help and addresses the issue of increasing anxiety and difficulty sleeping. It is supportive and guides the client toward discussing their concerns with a healthcare provider who can assess the situation and provide appropriate interventions.

D. "It sounds like you're having a difficult time" acknowledges the client's distress but does not guide them toward seeking professional help. Encouraging a conversation with a healthcare provider is a more direct and helpful approach.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a group of clients who have anxiety disorders and have prescriptions for various psychotropic medications. The nurse should recognize which of the following clients as having an increased risk for suicide?

Correct Answer is D

Explanation

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

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