A nurse is assessing a client with schizophrenia who is hearing voices. The client states, “They keep telling me to do something bad to myself.” Which of the following actions should the nurse take first?

Ask the client, “Can you tell me exactly what the voices are telling you to do?”

Remind the client that the voices are not real and encourage distraction techniques.

Escort the client to a quiet room and encourage deep breathing.

Notify the provider of the hallucination and request a medication adjustment.

Answer and Explanation

The Correct Answer is A

Choice A reason: The priority is to assess the content of the hallucinations to determine the level of risk. If the voices are commanding self-harm or violence, immediate safety interventions are required. This makes assessment the first and most critical step.

Choice B reason: Reminding the client that the voices are not real may be therapeutic later, but it does not address the immediate safety concern. Without knowing the content of the hallucinations, the nurse cannot determine risk.

Choice C reason: Escorting the client to a quiet room and encouraging relaxation may help reduce anxiety but does not address the potential danger of command hallucinations. Safety assessment must come first.

Choice D reason: Notifying the provider and requesting medication adjustment is appropriate after assessing the hallucination content. Immediate risk must be evaluated before treatment changes are considered.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: ECT is not the first-line treatment for depression. Antidepressant medications and psychotherapy are typically tried first.

Choice B reason: ECT is not a permanent cure for depression. It is highly effective but relapse can occur, requiring maintenance therapy.

Choice C reason: ECT is not primarily used for anxiety disorders. It is reserved for severe depression, catatonia, or treatment-resistant cases.

Choice D reason: ECT is particularly effective for patients with treatment-resistant depression, especially when symptoms are severe and life-threatening, such as suicidal ideation and significant weight loss. This makes it the most appropriate reason for choosing ECT in this case.

A. Determine if the client is having thoughts of harming themselves or others. B. Bargain with the client when setting behavioral expectations. C. Provide clear boundaries for behavior toward peers and staff members. D. Instruct the client on coping mechanisms and relaxation techniques. E. Encourage the client to verbalize their feelings. F. Establish consequences for unacceptable behaviors.

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A reason:
Clients with borderline personality disorder have a significantly elevated risk of suicide and self-harm. This client has a recent suicide attempt and a chronic history of non-suicidal self-injury. Assessing for current suicidal or homicidal thoughts is a fundamental safety intervention and prioritizes life-preserving needs. Frequent assessment prevents escalation of impulsive behavior, which is common with this disorder.

Choice B reason:
Bargaining with the client is inappropriate because it reinforces manipulation, a hallmark maladaptive behavior in borderline personality disorder. Bargaining undermines consistent limit-setting, leads to unstable therapeutic boundaries, and reinforces splitting behaviors. Therefore, it is not appropriate or therapeutic.

Choice C reason:
Clear, consistent boundaries provide structure that the client cannot maintain independently due to emotional instability and impulsivity. Limits reduce interpersonal chaos and help prevent episodes such as insulting staff impulsively, then panicking and fearing rejection. Structure allows the nurse to respond predictably, reducing anxiety and impulsivity.

Choice D reason:
Teaching coping mechanisms helps the client develop healthier responses to emotional distress, anxiety, and interpersonal triggers. Skills such as grounding, relaxation breathing, and guided imagery increase emotional regulation. Because this client reports chronic nervousness and difficulty sleeping and focusing, these techniques directly address distress and improve functioning.

Choice E reason:
Encouraging verbal expression of feelings reduces impulsive acting-out behaviors. When a client verbalizes emotions, they can process distress more effectively, decreasing maladaptive reactions such as outbursts or self-harm. This builds trust and supports therapeutic communication, a key component of care for borderline personality disorder.

Choice F reason:
Clients with borderline personality disorder benefit from clear consequences for unacceptable behaviors because it promotes responsibility and reduces impulsivity. Consequences must be consistent, firm, and non-punitive. This intervention strengthens boundaries and helps the client understand behavioral expectations in a structured environment.

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A nurse is assessing a client with schizophrenia who is hearing voices. The client states, “They keep telling me to do something bad to myself.” Which of the following actions should the nurse take first?

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Correct Answer is D

Explanation

A nurse on a mental health unit is caring for a client Exhibits The nurse is planning care for the client. Which of the following actions should the nurse plan to take? (Select all that apply.)

Correct Answer is ["A","C","D","E","F"]

Explanation

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