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."

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

a. Clean the stoma using an inward to outward circular motion.

When providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma. Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.

When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three. Finally, the nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.

A. Maintain low-level lights in common areas. B. Give the client several meal options at lunchtime. C. Confront the client regarding inappropriate behavior. D. Use symbols in the communal room signage.

Correct Answer is D

Explanation

A.Maintain low-level lights in common areas.Inadequate lighting can contribute to disorientation and falls. Well-lit areas with natural or soft lighting are preferable.

B.Give the client several meal options at lunchtime.Too many choices can be overwhelming and increase confusion. Instead, limiting choices (e.g., offering just two meal options) is a better approach.

C.Confront the client regarding inappropriate behavior.Confrontation can increase agitation and distress. Instead, redirection and gentle guidance are more effective strategies.

D. Use symbols in the communal room signage.Clients experiencing confusion and memory loss benefit from visual cues and simple, clear communication. Using symbols (such as pictures of a toilet for the restroom or a plate for the dining area) can help them navigate the environment more easily and reduce frustration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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