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 A
Explanation
A. Documenting the transfusion reaction in the medical record is essential for accurate documentation and communication among the healthcare team.
B. Administering epinephrine subcutaneously is not indicated for febrile transfusion reactions. It is instead indicated for anaphylaxis.
C. Infusing lactated Ringer's IV may be indicated for managing transfusion reactions, but the specific treatment depends on the type and severity of the reaction. It's essential to consult with the healthcare provider for appropriate interventions.
D. Placing the blood bag in a biohazard bag before discarding is a routine procedure for disposing of blood products but is not the immediate priority when managing a transfusion reaction.
Correct Answer is A
Explanation
A. Raised facial rash, often in a "butterfly" distribution across the cheeks and bridge of the nose, is a characteristic manifestation of systemic lupus erythematosus.
B. Hemangiomas are not typically associated with systemic lupus erythematosus.
C. Kaposi's sarcoma lesions are associated with immunosuppression, such as in HIV infection, and are not a typical finding in systemic lupus erythematosus.
D. Psoriasis is a separate autoimmune condition characterized by red, scaly patches on the skin and is not typically associated with systemic lupus erythematosus.
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