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 ["A","B","D","F","G","I","J"]

Explanation

Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.

Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.

Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.

Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.

Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.

Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.

Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.

A. Apply the patch within 1 hr of removing it from the protective pouch. B. Shave hairy areas of skin prior to application. C. Wear gloves to apply the patch to the client's skin. D. Remove the previous patch and place it in a tissue.

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.

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Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

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

Correct Answer is ["A","B","D","F","G","I","J"]

Explanation

A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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