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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

A. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." B. "The devil only talks to people who are receptive to his influence." C. "You are not going to hell. You are a good person." D. "Did you take your medicine this morning?"

Correct Answer is A

Explanation

a. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." Validating the experience ("The voices must sound scary") shows empathy and avoids dismissing the client's reality. Explaining it as part of the illness ("This is part of your illness") provides a non-judgmental explanation.
b. "The devil only talks to people who are receptive to his influence." Denying the voices can be dismissive and make the client feel isolated.
c. "You are not going to hell. You are a good person." While offering reassurance might seem comforting, it doesn't address the specific hallucination.
d. "Did you take your medicine this morning?" Medication is important, but the immediate priority is to address the hallucination and provide support.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At what point should the nurse determine that a client is at risk for developing mental illness? When:

Correct Answer is B

Explanation

A client diagnosed with schizophrenia disorder states, "Can't you hear them? It's the devil. The devil is telling me I'm going to hell." Which is the most appropriate nursing response?

Correct Answer is A

Explanation

A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

The client hears the word "match." The client replies, "A match. I like matches. They are the light of the world. God will light the world. Let your light shine." Which communication pattern does the nurse identify?

A client has recently been diagnosed with Alzheimer's disease. Which medication would the nurse expect the physician to order for this client's cognitive impairment?

A client takes the morning dose of 10 units of insulin aspart at 0800. At what time interval would the nurse most likely see hypoglycemia?

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia disorder, tells them that voices command the child to harm others. Which is the appropriate nursing response?

A client who is agitated and assaultive and unable to be verbally de-escalated is on the inpatient unit. The doctor ordered medications for the nurse to administer to the client. Which medication would the nurse question?

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?