A client diagnosed with Schizophrenia states, "The voices won't leave me alone!" Which of the following statements should the nurse make?
"Are the voices telling you to harm yourself or someone else?"
"The voices are not real or we would both hear them."
"Why are the voices talking to only you?"
"Why didn't you ask the voices to go away?"
The Correct Answer is A
A. "Are the voices telling you to harm yourself or someone else?": This response directly assesses for command hallucinations, which may increase the risk of self-harm or violence. Safety is the priority, and clarifying the content of the hallucinations helps guide immediate interventions.
B. "The voices are not real or we would both hear them.": This approach challenges the client’s perception and can increase defensiveness or mistrust. Denying the hallucination does not promote therapeutic communication or ensure safety.
C. "Why are the voices talking to only you?": This response is non-therapeutic and may make the client feel ridiculed or invalidated. It does not provide support or assess the potential danger of the hallucinations.
D. "Why didn't you ask the voices to go away?": This places responsibility on the client to control the hallucination, which they cannot do. It is dismissive of the distress they are experiencing and fails to address safety concerns associated with auditory hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administration of oxygen is contraindicated in clients who are using bronchodilators: Oxygen therapy is not contraindicated with bronchodilators. In fact, bronchodilators and oxygen are commonly used together to relieve airway obstruction and improve gas exchange in COPD.
B. High oxygen concentrations will cause coughing and dyspnea: While oxygen therapy can sometimes dry airways or cause minor irritation, coughing and dyspnea are not direct effects of high oxygen concentration. Dyspnea in COPD is due to impaired gas exchange and airflow limitation.
C. Increased oxygen use will cause the client to become dependent on the oxygen: Oxygen therapy does not create physical dependence. Clients with COPD may require long-term oxygen due to disease progression, but this is related to their chronic hypoxemia rather than dependency.
D. High oxygen concentration may inhibit the hypoxic stimulus to breathe: Clients with COPD often rely on hypoxemia as their primary drive to breathe, since chronic CO₂ retention blunts the normal hypercapnic drive. Administering high oxygen concentrations can suppress this hypoxic drive, leading to hypoventilation and CO₂ narcosis.
Correct Answer is D
Explanation
A. "I can get a supply of the medication for 60 days at a time": Clozapine requires frequent blood monitoring because of the risk of agranulocytosis. Clients are usually dispensed only a 1–2 week supply at a time depending on lab results.
B. "I may have a fatal response if I go outside and develop a rash": Clozapine is not associated with fatal skin reactions from sunlight exposure, its most critical concern is blood dyscrasias such as agranulocytosis.
C. "I need to have monthly cytokines tests for up to a year": Clients on clozapine require weekly complete blood counts (CBCs) for the first 6 months, then every 2 weeks for the next 6 months, and monthly only after a year if stable. Cytokine testing is not part of clozapine monitoring.
D. "I should call the health care provider if I develop a sore throat and fever": Sore throat and fever may signal agranulocytosis or severe neutropenia, which are potentially life-threatening side effects of clozapine. Prompt reporting ensures early intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.