The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

The voices you are hearing are not real

Let’s talk about the next time this happens

You need to be calm and focus on something else

You appear to be speaking with someone

None

Answer and Explanation

The Correct Answer is D

A. Telling the client that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

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Correct Answer is B

Explanation

A. While marijuana may not be considered highly addictive compared to some substances, the response should address the potential risks and consequences of marijuana use rather than focusing solely on addiction.
B. This response highlights the immediate concern of altering one's ability to think clearly, emphasizing potential risks to both the individual and others.
C. Healthcare providers prescribing marijuana for specific medical purposes does not directly address the student's concern about recreational use.
D. Discussing moral implications may be a subjective approach and may not provide concrete information about the potential risks associated with marijuana use.

A. Tell the client to discuss his ideas with others when his thoughts are more clear. B. Teach the client to slow down and focus on the topic by listening to his words. C. Ask the client to repeat his comments. D. Confront the client when he talks rapidly.

Correct Answer is B

Explanation

A. Telling the client to discuss his ideas when his thoughts are more clear may not be effective as it does not provide immediate guidance on improving communication.
B. Teaching the client to slow down and focus on the topic by listening to his words is a therapeutic intervention to address tangential speech and promote effective communication.
C. Asking the client to repeat his comments may not directly address the issue of tangential speech and may not be as therapeutic as providing guidance on communication techniques.
D. Confronting the client when he talks rapidly may be perceived as confrontational and may not be the most therapeutic approach to address tangential speech.

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The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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