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 A
Explanation
A. Fever is a common manifestation of bacterial pneumonia, as it indicates the body's immune response to infection. Other typical symptoms include cough, shortness of breath, chest pain, and sputum production.
B. Drooling is not typically associated with bacterial pneumonia but may occur in conditions such as epiglottitis or aspiration pneumonia.
C. Tinnitus is not a characteristic manifestation of bacterial pneumonia but may occur with other conditions affecting the ear.
D. Steatorrhea refers to fatty stools and is not associated with pneumonia.
Correct Answer is B
Explanation
A. Epoetin alfa does not directly affect platelet count.
B. Epoetin alfa is a medication used to stimulate red blood cell production in patients with anemia. A therapeutic response to epoetin alfa would include an increase in hemoglobin level, indicating improved oxygen-carrying capacity of the blood.
C. Epoetin alfa does not directly affect neutrophil count.
D. Erythrocyte sedimentation rate is a nonspecific marker of inflammation and is not directly affected by epoetin alfa.
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