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. Setting a routine, including a toileting schedule, helps manage incontinence and reduces confusion and anxiety for a client with dementia. Regular schedules provide structure and can improve cooperation and quality of life.
B. Simplifying clothing with easy fasteners like Velcro instead of buttons and zippers can help maintain independence in dressing for a person with dementia.
C. Physical activity should be encouraged as it can help reduce agitation, improve mood, and promote better sleep patterns.
D. Excessive sensory stimulation can be overwhelming and confusing for clients with dementia; activities should be calming and familiar.

A. "The client is exceptionally clingy to others." B. "The client might act seductively." C. "The client exhibits impulsive behavior." D. "The client is overly concerned about minor details."

Correct Answer is C

Explanation

A. Borderline personality disorder is characterized more by unstable and intense interpersonal relationships rather than clinginess.
B. While some individuals with borderline personality disorder may exhibit manipulative behaviors, this does not universally manifest as seductiveness.
C. Impulsivity, such as reckless spending or substance abuse, is a hallmark feature of borderline personality disorder, making it a crucial aspect to include in education about the condition.
D. Borderline personality disorder is not typically associated with excessive concern about minor details; instead, it's marked by a pattern of instability in mood, self- image, and behavior.

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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?

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Naxlex Comprehensive Predictor Exams

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