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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is C
Explanation
A. "A single dose of diazepam is unlikely to cause side effects" is not accurate. Diazepam, like any medication, can have side effects even with a single dose. Common side effects include drowsiness, dizziness, and muscle weakness.
B. "Grapefruit juice inactivates this medication" is not specifically true for diazepam. However, grapefruit juice can interact with certain medications by inhibiting their metabolism in the liver, leading to increased levels of the drug in the bloodstream. It's essential to check for specific drug interactions, but this statement is not a key consideration for diazepam.
C. "Diazepam can cause drowsiness" is an important piece of information to include because diazepam is a benzodiazepine medication that can have sedative effects. Alerting the client to the potential for drowsiness is crucial to prevent any safety issues, such as falls or accidents.
D. "Avoid foods that contain tyramine" is not relevant to diazepam. Tyramine is associated with certain foods and can be a concern with medications called monoamine oxidase inhibitors (MAOIs). Diazepam is not an MAOI, so this advice does not apply to its use.
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