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 D

Explanation

A. While determining if the procedure is medically necessary is important, the decision-making process should involve the client's designated surrogate, especially when the client is unable to make decisions.
B. While family support is valuable, the primary concern is ensuring that the client's designated surrogate, who is responsible for making healthcare decisions on behalf of the client, is informed and involved in the decision-making process.
C. Sending the unsigned informed consent form to the facility's risk manager does not address the immediate need to ensure that the client's healthcare surrogate is informed about the procedure and its implications.
D. When a client is unable to provide informed consent due to incapacitation, the nurse should communicate with the client's designated health care surrogate to ensure they are aware of the risks and benefits of the procedure and can make decisions on behalf of the client.

A. Give the dose over 60 min. B. Administer the medication undiluted. C. Inject 19% lidocaine prior to each dose. D. Obtain a trough level 30 min after the medication infusion.

Correct Answer is A

Explanation

A. Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B. Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C. Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.

D. Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.

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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

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

Correct Answer is A

Explanation

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