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 C

Explanation

A. Planning with the client for how he can better handle frustration (option A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.

B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.

C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.

D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.

A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently. B. Play loud music for the client in her room. C. Engage the client in a small group activity. D. Instruct the client to avoid napping during the day.

Correct Answer is A

Explanation

A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently.
Clients experiencing acute mania often have increased energy levels and may engage in hyperactive behaviors, leading to a high calorie expenditure. Offering high-calorie foods that can be eaten with hands and fluids frequently can help meet the increased energy needs of the client. It's important to ensure proper nutrition and hydration during the manic episode.

B. Playing loud music for the client in her room may exacerbate the heightened arousal and agitation associated with mania. It is important to create a calm and structured environment.

C. Engaging the client in a small group activity may be overwhelming and contribute to increased stimulation. Individual activities or smaller, quieter groups may be more appropriate for a client in acute mania.

D. Instructing the client to avoid napping during the day may not be practical. Clients in acute mania often have reduced need for sleep, and forcing them to avoid napping may increase agitation and restlessness. It's essential to balance rest with activity and monitor for signs of exhaustion.

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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

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