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 []
Explanation
Based on the provided nurses' notes, the client exhibits symptoms that may suggest a brief psychotic disorder, characterized by delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. The client's history of similar episodes and family history could support this diagnosis. To assess the client's progress, the nurse should monitor the client's ability to care for themselves and assess any suicide risk due to the client's recent stressors and emotional state. Actions that could be beneficial include reducing external stimuli to prevent sensory overload and engaging with the client several times each day to establish trust, which can help alleviate anxiety and foster a therapeutic environment.
Correct Answer is C
Explanation
A. Negligence refers to the failure to provide care that a reasonably prudent person would have under similar circumstances, resulting in harm to the patient.
B. Battery involves the intentional harmful or offensive contact with a person without their consent. While similar to assault, battery involves actual physical contact, such as forcibly inserting a urinary catheter without consent.
C. Assault occurs when a threat of harmful or offensive contact is made, causing fear or apprehension in the victim. In this scenario, the newly licensed nurse's statement of
inserting a urinary catheter without consent if the client does not void constitutes an act of assault.
D. Libel involves making defamatory statements in written or published form, which is not applicable in this scenario.
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