Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

"Why don't you discuss that with your physician?"

"I would rather you reconsider that decision."

"What happened the last time you stopped taking your medication?"

"The physician prescribed that medication to help you."

Answer and Explanation

The Correct Answer is D

A.   This response may be seen as evading the client's statement. It's important to provide a more direct response.
B.   This response may come across as controlling or confrontational, which may not promote open communication.
C.   This response is a good therapeutic technique as it encourages the client to reflect on past experiences with stopping medication.
D.   This response provides a clear and factual statement about the purpose of the prescribed medication, encouraging the client to understand its importance.

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Correct Answer is A

Explanation

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

A. "Attempts to communicate by using rhyming words." B. "Nonverbals indicate communication with unseen others." C. "Verbalizes happiness about trip to park which was not based in fact." D. "Rambles about early childhood experiences jumping from topic to topic."

Correct Answer is C

Explanation

Confabulation involves the fabrication of details or events to fill in gaps in memory. In this case, the client is expressing happiness about a trip to the park that did not actually occur, which is an example of confabulation.

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Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Correct Answer is A

Explanation

Which nursing documentation entry accurately describes a client's use of confabulation?

Correct Answer is C

Explanation

When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what side effect in a client?

The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?

During the admission process, an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?