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?"

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "The next scheduled nebulizer treatment will be skipped.": Skipping the next treatment without evaluation may compromise airway management. Albuterol is essential for bronchodilation, and withholding it could worsen respiratory distress.

B. "This is an expected side effect, but let me take your pulse.": Anxiety and tremors are common side effects of albuterol due to its beta-adrenergic stimulation. Monitoring the pulse is appropriate since tachycardia is a possible adverse effect requiring close observation.

C. "I will hold the respiratory medication for 24 hours.": Holding albuterol for 24 hours is unsafe, as the client may experience worsening bronchospasm or hypoxemia. Adjustments should only be made with provider guidance, not independently by the nurse.

D. "I will request medication for anxiety from the healthcare provider.": Anxiety in this context is a medication side effect, not a psychiatric condition. Treating it with additional medication is unnecessary when monitoring and reassurance are more appropriate.

A. What condition is this client experiencing? B. Pleural effusion C. Asthma exacerbation D. Pneumothorax E. Pulmonary embolism

Correct Answer is C

Explanation

A. Pleural effusion: This involves fluid accumulation in the pleural space, leading to diminished breath sounds and dyspnea. However, it typically develops gradually, not with sudden onset following trauma.

B. Asthma exacerbation: Asthma usually presents with wheezing, prolonged expiration, and airway inflammation. The absence of wheezing and the presence of unequal chest excursion make this less likely.

C. Pneumothorax: Sudden chest pain, dyspnea, decreased breath sounds, and unequal chest excursion strongly suggest pneumothorax. The history of trauma increases the likelihood, as air enters the pleural space causing lung collapse.

D. Pulmonary embolism: This causes sudden dyspnea and chest pain, but breath sounds are usually normal or clear. The presence of trauma, decreased breath sounds, and unequal chest expansion makes pulmonary embolism less consistent with this case.

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A client diagnosed with Schizophrenia states, "The voices won't leave me alone!" Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving an albuterol nebulizer, a client complains of feeling anxious and shaky. Which response by the nurse is best?

Correct Answer is B

Explanation

A 28 y.o. female presents to the ED with sudden onset of chest pain and difficulty breathing after a fall from her bicycle. She reports a history of smoking. On examination, decreased breath sounds and unequal chest excursion.

Correct Answer is C

Explanation

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