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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
A. This statement is incorrect because tuberculosis treatment typically lasts longer than a week, and the client may remain contagious until the infectiousness subsides, which usually occurs after a few weeks of treatment.
B. TB treatment typically lasts for 6 months, not 6 weeks.
C. Rifampin, one of the medications for tuberculosis, can cause red-orange discoloration of body fluids (including tears, saliva, and urine), and can typically discolor contact lenses.
D. Directly observed therapy (DOT) is a recommended strategy for tuberculosis treatment to ensure medication adherence. Having someone observe the client taking their medication helps to confirm compliance and reduces the risk of non- adherence.
E. This statement is incorrect because alcohol consumption can interact with some tuberculosis medications, leading to potential liver toxicity or reducing the effectiveness of the drugs.
F. This statement demonstrates an understanding of the importance of informing the healthcare provider about any new medications. It's crucial to avoid potential interactions between tuberculosis medications and other drugs.
G. The Mantoux test is typically not repeated during tuberculosis treatment unless there is a specific clinical indication, such as an initial negative test with ongoing symptoms or exposure.
Correct Answer is A
Explanation
To calculate the IV infusion rate for dopamine hydrochloride, we first need to convert the dose from micrograms per kilogram per minute (mcg/kg/min) to milligrams per hour (mg/hr). The patient weighs 80 kg and the prescribed dose is 4 mcg/kg/min.
First, calculate the dose in mcg/hr: 4 mcg/kg/min x 80 kg x 60 min/hr = 19200 mcg/hr.
Next, convert mcg to mg: 19200 mcg/hr / 1000 mcg/mg = 19.2 mg/hr.
We have an 800 mg dopamine hydrochloride solution in a 250 mL bag. To find out how many mL/hr to administer, we use the following proportion:
(800 mg / 250 mL) = (19.2 mg / X mL).
Solving for X gives us X = (19.2 mg * 250 mL) / 800 mg, which equals 6 mL/hr.
Therefore, the nurse should set the IV infusion pump to deliver 6 mL/hr.
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