A nurse is caring for a client who has a substance use disorder. The client states, "The state took my child away after my overdose. I don't want to go on living without them." Which of the following therapeutic responses should the nurse make?

"If you attend counseling, you will get your child back."

"We can ask the physician to prescribe a sedative."

"Have you thought about harming yourself?"

"Can a family member try to obtain temporary custody of your child?"

Answer and Explanation

The Correct Answer is C

Choice A reason: This response is not therapeutic as it provides false assurance and may not be accurate. The return of the child depends on many factors beyond just attending counseling.

Choice B reason: While sedatives may be used to manage acute distress, this response does not address the client's expressed feelings of hopelessness and the risk of self-harm.

Choice C reason: This response directly addresses the client's statement about not wanting to live, which could indicate suicidal ideation. It is important to assess for the risk of self-harm or suicide.

Choice D reason: This response may be helpful in a long-term plan but does not address the immediate risk of harm to the client. It is also not guaranteed that a family member can obtain custody.

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Correct Answer is B

Explanation

Choice A reason: Avoiding television when hearing voices is not a recognized strategy for relapse prevention in schizophrenia. While reducing stimuli during episodes of auditory hallucinations can be helpful, it is not a substitute for professional treatment and medication adherence, which are key to relapse prevention.

Choice B reason: Informing a counselor about trouble sleeping is important because sleep disturbances can be an early indicator of a potential relapse. Maintaining open communication with healthcare providers about changes in sleep patterns allows for timely interventions and adjustments in treatment to prevent a relapse.

Choice C reason: Listening to the voices is not advisable as it may reinforce the hallucinations. Instead, clients are encouraged to engage in reality-based activities and to discuss their experiences with their healthcare providers to manage symptoms effectively.

Choice D reason: Isolation can exacerbate symptoms of schizophrenia and increase the risk of relapse. It is important for individuals to maintain social contacts and support systems as part of a comprehensive relapse prevention strategy.

A. "Have you noticed that your taste has decreased?" B. "Have you noticed an increase in thirst?" C. "Have you noticed unintentional weight loss?" D. "Have you noticed a ringing in your ears?"

Correct Answer is B

Explanation

Choice A reason: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.

Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.

Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.

Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.

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A nurse is caring for a client who has a substance use disorder. The client states, "The state took my child away after my overdose. I don't want to go on living without them." Which of the following therapeutic responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

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