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 C

Explanation

A. Alprazolam is a benzodiazepine used for anxiety and should not necessarily be discontinued solely based on discontinuation of an antipsychotic.
B. Lithium is a mood stabilizer commonly used in bipolar disorder but is not necessarily discontinued with the discontinuation of an antipsychotic.
C. Benztropine is an anticholinergic medication often used to manage extrapyramidal symptoms (EPS) associated with antipsychotic medications. If the antipsychotic is discontinued,
benztropine may also be discontinued.
D. Magnesium is not typically associated with antipsychotic use, and its discontinuation would depend on the specific indication and circumstances.

A. Avoid discussing subjects that upset the client B. Encourage activities that allow the client to exert control over his environment. C. Allow the client time alone to sort out his feelings. D. Encourage the client to interact with persons who are recovering from depression.

Correct Answer is B

Explanation

A. Avoiding discussing subjects that upset the client may hinder therapeutic communication and exploration of feelings, making it less effective for the client's recovery.
B. Encouraging activities that allow the client to exert control over his environment helps empower the client and regain a sense of agency, which is important for improving mental health.
C. Allowing the client time alone may be appropriate at times, but encouraging activities that promote control is a more proactive and empowering intervention.
D. Encouraging interaction with persons recovering from depression may be beneficial, but the client's need for control over his environment takes precedence in this scenario.

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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

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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