A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse. Where do the voices come from? Which is the appropriate nursing reply?

Your child has a chemical imbalance of the brain, which leads to altered thoughts

Your child's hallucinations are caused by medication interactions

your child has too little serotonin in the brain causing delusions and hallucinations

your child's abnormal hormonal changes have precipitated auditory hallucinations

Answer and Explanation

The Correct Answer is A

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.

B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.

C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.

D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.

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Correct Answer is B

Explanation

Client diagnosed with hypomania who is speaking loudly on the unit: While hypomanic individuals may exhibit increased energy and talkativeness, the urgency is lower compared to a client expressing active suicidal ideations. This client does not pose an immediate threat to themselves or others.

B. Client diagnosed with mania who expressed active suicidal ideations: This is the correct answer. A client with active suicidal ideations is at an elevated risk and requires immediate attention. Suicidal thoughts in the context of mania can be impulsive, and prompt intervention is crucial to ensure the client's safety.

C. Client with a history of mania who is pacing in the hallway: Pacing may be a symptom of mania, but without additional information about the client's current state and any potential immediate risks, the client expressing active suicidal ideations takes precedence.

D. Client diagnosed with hypomania who is complaining of pain: Pain complaints, in the absence of other urgent factors, do not take precedence over active suicidal ideations. The risk of harm to oneself or others is a higher priority.

A. A client diagnosed I with hypomania who is speaking loudly on the unit. B. A client diagnosed with hypomania who is complaining of pain. C. A client with a history of mania who is pacing in the hallway D. A client diagnosed with mania who expressed active suicidal ideations

Correct Answer is D

Explanation

A. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.

B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.

C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.

D.A client diagnosed with mania who expressed active suicidal ideations

In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.

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A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse. Where do the voices come from? Which is the appropriate nursing reply?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

Correct Answer is B

Explanation

A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

Correct Answer is D

Explanation

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