A nurse in an inpatient mental health facility sees a client who is talking while walking alone. The client tells the nurse, "This guy in my head says I am to blame for my own illness." Which of the following responses should the nurse make?

"It is not possible to have someone else in your head talking to you."

"Why do you think he is telling you what to do?"

"Although I can't hear that voice, it must be very upsetting for you."

"Are you sure it wasn't your roommate telling you that?"

Answer and Explanation

The Correct Answer is C

A. "It is not possible to have someone else in your head talking to you." This dismisses the client’s experience and can make them feel invalidated or misunderstood. Such responses damage rapport and may discourage further communication or trust in the therapeutic relationship.

B. "Why do you think he is telling you what to do?" This response presses the client to analyze their hallucination, which may increase anxiety or confusion. It also shifts focus away from support and validation, which should be the priority during such disclosures.

C. "Although I can't hear that voice, it must be very upsetting for you." This response acknowledges the client’s feelings without reinforcing the hallucination. It maintains therapeutic boundaries while expressing empathy, helping the client feel heard and supported.

D. "Are you sure it wasn't your roommate telling you that?" This questions the client’s reality and can cause distress or frustration. Challenging a hallucination in this manner is not therapeutic and may make the client defensive or confused.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I will remove the yellow exudate that forms around his penis." The yellow exudate is part of normal healing and should not be removed. Disturbing this layer can delay healing and increase the risk of bleeding or infection.

B. "I will apply petrolatum to his penis with each diaper change." Applying petrolatum helps prevent the diaper from sticking to the healing circumcision site, reducing discomfort and protecting the wound from friction and contamination during diaper changes.

C. "I will change his diaper every 6 hours." Diapers should be changed more frequently, especially after each bowel movement or urination, to keep the area clean and dry and reduce the risk of infection at the circumcision site.

D. "I will ensure that the diaper is firmly applied to the circumcised area." The diaper should be applied snugly but not firmly or tightly. Excess pressure on the circumcised area can cause pain or impair circulation, delaying healing.

A. An assistive personnel arrives for her shift with alcohol on her breath. B. A client's family member falls in the unit hallway. C. A client does not have advance directives in his medical record. D. A client refuses a blood transfusion.

Correct Answer is B

Explanation

A. An assistive personnel arrives for her shift with alcohol on her breath:This situation requires immediate reporting to the supervisor and removal of the staff member from duty, but it does not call for an incident report unless it results in a safety event or client harm.

B. A client’s family member falls in the unit hallway:An incident report is required for any unplanned event that occurs on the premises and poses a risk of injury or liability, including visitor falls. This documentation is important for legal protection and quality improvement.

C. A client does not have advance directives in his medical record:The absence of advance directives is a legal and ethical issue that should be addressed during admission, but it does not represent an error or adverse event requiring an incident report.

D. A client refuses a blood transfusion:Refusal of treatment is a patient’s right and should be documented in the medical record. It is not a mistake or accident, so it does not necessitate an incident report unless a related error or adverse event occurs.

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 nurse in an inpatient mental health facility sees a client who is talking while walking alone. The client tells the nurse, "This guy in my head says I am to blame for my own illness." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who is 3 days postpartum about her infant's circumcision using a Gomco clamp. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is planning care for a group of clients. Which of the following situations requires the nurse to complete an incident report?

Correct Answer is B

Explanation

A nurse is teaching a client who has a new prescription for oral prednisone about minimizing the adverse effects of the medication. Which of the following statements by the client indicates an understanding of the teaching?

A nurse in an antepartum unit is caring for a client. Exhibits For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

A nurse is reviewing the laboratory results from a cerebrospinal fluid test for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

A nurse is implementing seizure precautions for a newly admitted client. Which of the following equipment should the nurse place in the client's room?

A nurse is caring for a client who is in labor and receiving dextrose 5% in 0.9% sodium chloride at 250 ml/hr intravenously. The client had 50 mL of urinary output in the last 4 hr. Which of the following actions should the nurse take?

A nurse is providing teaching to a client who has a prescription for a quadruple marker screen. Which of the following statements by the client demonstrates an understanding of the teaching?

A nurse is reviewing laboratory data for a client who has a new prescription for valproic acid. Which of the following baseline results should the nurse review prior to administering the first dose of the medication?