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 B

Explanation

A. The palms of the hands are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
B. Jaundice is characterized by the yellowing of the skin and eyes due to high levels of bilirubin in the blood. In individuals with dark skin, this yellowing may not be as apparent on the skin itself, making the sclera a more accurate site for assessment.
C. The shoulders are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
D. The face is less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.

A. Use up to 40 nicotine lozenges per day. B. Substitute tobacco use with an electronic cigarette. C. Limit use of nicotine gum to 6 months. D. Use progressively larger nicotine patches.

Correct Answer is C

Explanation

A. Using up to 40 nicotine lozenges per day is excessive and may lead to nicotine toxicity.

B. Substituting tobacco use with an electronic cigarette is not recommended due to potential health risks associated with vaping.
C. Nicotine replacement therapy, such as nicotine gum, should be used for a limited duration to avoid dependence. The nurse should educate the client to limit the use of nicotine gum to no more than 6 months to achieve smoking cessation goals effectively.
D. Using progressively larger nicotine patches is not a standard practice and may increase the risk of nicotine overdose.

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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 performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for jaundice?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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