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: Alternative communication methods are more applicable to clients with severe speech or cognitive impairments, which are not universally present in multiple sclerosis.
B: Using clock numbers to describe food placement is typically recommended for visually impaired clients, not specifically for those with multiple sclerosis.
C: Touching the client's arm before speaking is a technique used for clients with hearing impairments.
D: Multiple sclerosis can cause fine motor skill impairment and muscle weakness. Providing large-handled utensils can help maintain independence in eating by making it easier to grip and use utensils.

A. "Take your temperature immediately after waking and before getting out of bed." B. "Take your temperature 1 hour after getting out of bed." C. "Take your temperature every night before going to bed." D. "Take your temperature within 30 minutes after your first morning void."

Correct Answer is A

Explanation

A. Basal body temperature should be measured immediately upon waking and before any physical activity to ensure accuracy in detecting the slight temperature rise after ovulation.
B. Temperature taken after getting out of bed may not accurately reflect the basal body temperature.
C. Basal body temperature is best measured in the morning.

D. The timing here still allows for too much activity before measuring temperature, which can affect the reading.

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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 contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition?

Correct Answer is D

Explanation

A nurse is teaching a client about family planning using the basal body temperature method. Which of the following Instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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