A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

"That can't be true. The only voices in this room are yours and mine."

"You shouldn't be afraid when you think the voices are telling you to hurt yourself."

"I understand the voices are frightening you, but I do not hear any voices."

"Do you recognize the voices as belonging to anyone you know?"

Answer and Explanation

The Correct Answer is C

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

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Correct Answer is A

Explanation

A. Since vitamin B12 is primarily found in animal products, clients following a vegan diet should be advised to consume fortified foods or supplements containing vitamin B12 to prevent deficiency.
B. High-fat cheese is not a suitable meat substitute for individuals following a vegan diet, as it is an animal-derived product.
C. Nuts and legumes are valuable sources of protein and other nutrients in a vegan diet and should not be limited unless there are specific dietary restrictions or preferences.
D. Foods high in vitamin C are beneficial for overall health, but limiting them is not necessary for individuals following a vegan diet.

A. Ketorolac B. Omeprazole C. Metoclopramide D. Acetaminophen

Correct Answer is D

Explanation

A. Ketorolac is an NSAID that carries a risk of gastrointestinal bleeding and is contraindicated in clients with cholelithiasis due to its potential to cause biliary colic.
B. Omeprazole is a proton pump inhibitor used to reduce gastric acid secretion and prevent ulcers but does not provide immediate pain relief.
C. Metoclopramide is a prokinetic agent that helps with gastric emptying and may be used to relieve symptoms such as nausea and vomiting but is not indicated for pain relief.

D. Acetaminophen is a suitable PRN pain medication for a client experiencing moderate abdominal pain due to cholelithiasis. It provides effective analgesia without exacerbating symptoms or causing adverse effects on the gastrointestinal system, which is crucial for clients with gallstone-related pain.

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A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer?

Correct Answer is D

Explanation

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