A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?
"I'm sure the voices will go away soon."
"Let's talk about what the voices are saying to you."
"You should talk to your counselor about the voices."
"Tell me what medications you are taking."
The Correct Answer is B
This response acknowledges the client's experience and shows a willingness to understand and address their concerns.
It opens up a dialogue about the hallucinations, allowing the nurse to gather more information and assess the client's current mental state. It also demonstrates empathy and support, which can help build trust between the nurse and the client.
Offering to discuss the voices with the client can also help in developing coping strategies and exploring potential interventions to manage the hallucinations effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should identify the sudden increase in energy as the priority finding to report to the provider. This could be a sign of an emerging manic episode, especially if the client is taking an antidepressant alone without a mood stabilizer.
It may indicate a switch to a manic state or the development of bipolar disorder. The provider needs to be informed promptly so that appropriate assessment and interventions can be implemented to ensure the client's safety and well-being.
Correct Answer is C
Explanation
Proteinuria can indicate kidney dysfunction or potential complications in pregnancy, such as preeclampsia. The provider needs to be aware of this finding and may want to assess the client further and consider appropriate interventions.
The other laboratory values are within normal ranges and do not require immediate reporting. Hgb (hemoglobin) of 13.2 g/dL is within the normal range for pregnancy. BUN (blood urea nitrogen) of 15 mg/dL is within the normal range, indicating normal kidney function. Fasting blood glucose of 72 mg/dL is within the normal range and indicates normal blood sugar levels.
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