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.

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Correct Answer is C

Explanation

a. His wife has minimal family support: While limited family support might affect the caregiver’s burden, it does not directly imply immediate safety concerns for the client.
b. His wife works from home in telecommunication: Working from home can be beneficial as she is physically present to assist the client.
c. The client smokes one pack of cigarettes per day. Smoking increases the risk of cardiovascular events and other health complications, which can exacerbate symptoms of vascular NCD and pose safety risks.
d. The client has worked nightshift his entire life. While working night shifts might affect his sleep patterns, it does not pose an immediate safety concern compared to the risk associated with smoking.

A. can stop taking this medication abruptly without serious complications." B. will need scheduled blood work in order to monitor for toxic levels of this drug C. will not drink alcohol while taking this medication." D. Will have to take this medication for the rest of my life."

Correct Answer is C

Explanation

a. Can stop taking this medication abruptly without serious complications: Abruptly stopping diazepam, especially after long-term use, can lead to withdrawal symptoms like anxiety, seizures, and insomnia.
b. Will need scheduled blood work in order to monitor for toxic levels of this drug: While monitoring might be necessary in some cases, it's not typical for everyone on diazepam.
c. Will not drink alcohol while taking this medication. (Correct) Diazepam is a central nervous system depressant. Alcohol has similar effects, and combining them can significantly increase the risk of drowsiness, impaired coordination, and respiratory depression. Understanding this interaction is crucial for safe medication use.
d. Will have to take this medication for the rest of my life: The duration of diazepam therapy depends on the individual and the condition being treated.

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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?

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Naxlex Comprehensive Predictor Exams

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