A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

Did you take your medicine this morning?

i'm sure the voices sound scary, I don't hear any voices speaking

The devil only talks to people who are receptive to his influence

You are not going to hell. You are a good person

Answer and Explanation

The Correct Answer is B

A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.

B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.

C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.

D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.

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Correct Answer is B

Explanation

A. "I will take Lithobid on an empty stomach": This statement is incorrect. Lithobid is usually taken with meals or right after meals to minimize gastrointestinal side effects. Taking it on an empty stomach may lead to increased side effects.

B. "I will maintain normal salt intake": This statement is correct. Lithium levels in the blood can be influenced by sodium levels. Maintaining a consistent and normal salt intake is important for the proper functioning of lithium in the body. Both low and high sodium levels can affect lithium levels.

C. "I will consume more fluids": This statement is generally correct. Adequate fluid intake is important to prevent dehydration, as lithium is excreted by the kidneys. However, it should be balanced, and excessive fluid intake should be avoided to prevent lithium toxicity.

D. "I will limit my intake of fluids daily": This statement is incorrect. While fluid intake should be monitored and maintained at a reasonable level, restricting fluids too much can lead to dehydration and an increased risk of lithium toxicity.

A. hypotensive shock B. hypertensive crisis C. cardiac dysrhythmia D. cardiogenic shock

Correct Answer is B

Explanation

A. Hypotensive shock: This is not the correct answer. MAO inhibitors are not associated with causing hypotensive shock. In fact, they can lead to an increase in blood pressure.

B. Hypertensive crisis: This is the correct answer. MAO inhibitors interact with certain foods and drugs, such as those containing tyramine, leading to an increased risk of a hypertensive crisis. Foods rich in tyramine, such as aged cheeses, certain wines, and some processed meats, can cause a sudden and dangerous increase in blood pressure when combined with MAO inhibitors.

C. Cardiac dysrhythmia: While all medications have potential side effects, MAO inhibitors are not typically associated with causing cardiac dysrhythmias.

D. Cardiogenic shock: MAO inhibitors are not known to cause cardiogenic shock. The primary concern with MAO inhibitors is the potential for a hypertensive crisis due to interactions with specific foods and drugs.

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A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

Correct Answer is B

Explanation

A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:

Correct Answer is B

Explanation

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