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 C
Explanation
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
Correct Answer is D
Explanation
A. Ketorolac is an NSAID that carries a risk of gastrointestinal bleeding and is contraindicated in clients with cholelithiasis due to its potential to cause biliary colic.
B. Omeprazole is a proton pump inhibitor used to reduce gastric acid secretion and prevent ulcers but does not provide immediate pain relief.
C. Metoclopramide is a prokinetic agent that helps with gastric emptying and may be used to relieve symptoms such as nausea and vomiting but is not indicated for pain relief.
D. Acetaminophen is a suitable PRN pain medication for a client experiencing moderate abdominal pain due to cholelithiasis. It provides effective analgesia without exacerbating symptoms or causing adverse effects on the gastrointestinal system, which is crucial for clients with gallstone-related pain.
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