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 C

Explanation

A. Transdermal nicotine patches should be applied immediately after removal from the protective pouch, but waiting for up to 1 hour is acceptable according to most manufacturers' instructions.
B. Shaving hairy areas of skin is not necessary prior to applying a transdermal nicotine patch and may cause skin irritation.
C. Wearing gloves during the application of the transdermal nicotine patch helps to prevent nicotine absorption through the nurse's skin and reduces the risk of accidental exposure.
D. The nurse should properly dispose of the previous patch according to facility protocols rather than placing it in a tissue, as used nicotine patches can still contain active medication and pose a risk of exposure.

A. Ensuring that a client who is homeless receives preventive medical care B. Being honest with the parents of a child about the need to report suspected abuse C. Accepting the decision of an older adult client to live alone in her home D. Keeping a promise to visit with a client who is housebound after the delivery of care

Correct Answer is A

Explanation

A. Distributive justice involves the fair allocation of resources and benefits to all members of society. By ensuring that a homeless client receives preventive medical care, the nurse is promoting fairness and equity in healthcare access.
B. Honesty with the parents about reporting suspected abuse is related to ethical principles such as veracity and autonomy, not distributive justice.

C. This choice involves respect for autonomy rather than distributive justice.

D. This choice relates to the ethical principle of fidelity, ensuring that promises made to clients are upheld, rather than distributive justice.

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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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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?