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
Explanation
A. Contractions lasting 80 seconds, while prolonged, may occur in active labor and do not necessarily indicate a complication requiring immediate provider notification.
B. Early decelerations in the fetal heart rate are typically benign and are not typically concerning unless they are persistent or associated with other signs of fetal distress.
C. An FHR baseline of 170/min is above the normal range and may indicate fetal distress or other complications requiring further evaluation and possible intervention, necessitating prompt provider notification.
D. A temperature of 37.4°C (99.3°F) is within the normal range and does not typically require immediate provider notification unless accompanied by other concerning symptoms.
Correct Answer is A
Explanation
A: Warm showers can help relieve stiffness and pain associated with osteoarthritis by improving circulation and relaxing muscles.
B: Placing a large pillow under the knees can actually exacerbate joint stiffness and pain in osteoarthritis by forcing the knee into a bent position.
C: There is no specific recommendation to limit dietary phosphorus for osteoarthritis pain management.
D: Placing an ice pack directly on the skin can cause frostbite and damage to the skin; it should be wrapped in a cloth first.
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