A client who has schizophrenia is talking to the nurse and states, "Do you hear that? I am scared. The voices are telling me to do horrible things which of the following responses by the nurse is appropriate?
"You need to understand there are no voices"
What are the voices telling you to do?
What do you think is causing you to heal the voices?
"You need to tell the forces to leave you alone.
The Correct Answer is B
a. "You need to understand there are no voices": Denying the client's experience can be invalidating and unhelpful.
b. What are the voices telling you to do? (Correct)A key principle in responding to someone experiencing auditory hallucinations is to validate their experience and ask open-ended questions. This helps the client feel heard and allows the nurse to assess the severity of the situation and potential safety risks.
c. What do you think is causing you to hear the voices? While exploring the cause of hallucinations can be part of therapy, in the immediate situation, focusing on what the voices are saying and assessing safety is more important.
d. "You need to tell the forces to leave you alone": This is confrontational and doesn't acknowledge the client's fear. It might also reinforce the belief in the voices having power.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. 1030-1130: Insulin aspart is a rapid-acting insulin that typically peaks in 1-2 hours. Hypoglycemia is most likely to occur during the peak action time.
b. 1130-1230: This is beyond the typical peak action time for insulin aspart, making hypoglycemia less likely during this interval.
c. 1000: This falls within the typical peak action time of 1-2 hours for insulin aspart, making hypoglycemia possible but the interval is slightly too narrow to capture the full peak effect.
d. 0800-0830: Insulin aspart begins to act within 10-20 minutes, but hypoglycemia typically does not occur this soon after administration unless there is an issue with meal timing or dosage.
Correct Answer is C
Explanation
a. "I can make that promise to you based on nurse-client privilege." Nurse-client confidentiality is important, but it doesn't apply to threats of violence. The nurse has a duty to protect the client and others.
b. "Those kinds of thoughts will make your hospitalization longer." While true, this response doesn't directly address the safety concern and might be perceived as judgmental.
c. "I cannot promise that. Confidentiality does not include plans to hurt others." This is a clear and honest statement. It explains the limitations of confidentiality and prioritizes safety.
d. "You should share this thought with your psychiatrist." While encouraging the client to talk to a psychiatrist is a good suggestion, it doesn't directly address the confidentiality issue or the immediate threat.
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