A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
"What are the voices telling you?"
"Have you taken your medication today?"
"I realize the voices are real to you, but I don't hear anything."
"How long have you been hearing the voices?"
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.
Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.
Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.
Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. It's important to alternate breasts during feedings to ensure both breasts are stimulated and milk supply is well-maintained.
B. Incorrect. Manually expressing milk can help stimulate milk production and maintain milk supply; it typically does not decrease milk supply.
C. Correct. Frequent and effective breastfeeding, along with proper latching and milk removal, stimulates the production of more milk.
D. Incorrect. Breastfeeding should continue for as long as the baby is actively sucking and swallowing. Babies vary in their feeding patterns, and the length of time at each breast can differ. It's essential to ensure the baby is adequately fed and empties the breast to stimulate milk supply.
Correct Answer is D
Explanation
A. Incorrect. Documentation of sensitive material might have designated personnel, but this information does not need to be limited to the charge nurse.
B. Incorrect. Access to medical records should be limited to those with a need for that information, not every nurse in the facility.
C. Incorrect. Most facilities require more frequent password changes (e.g., every 90 days) to enhance security. Therefore, this statement may be inaccurate depending on the facility's policy.
D. Correct. Firewalls are security systems that are used to protect computer networks from unauthorized access. They are an important component of any computerized documentation system.
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