A nurse is caring for a client who has schizophrenia.
The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?
What are the voices saying to you?
Why are the voices talking to you?
Would you like to go to your therapy session now?
Have you missed your medication today?
The Correct Answer is A
Choice A rationale
Asking about the content of the voices helps the nurse assess for command hallucinations, which can pose a safety risk to the client or others. This open-ended question encourages the client to elaborate, providing crucial information about the severity, nature, and potential danger of the auditory stimuli, which is the primary goal of the assessment.
Choice B rationale
This question is counterproductive because it asks for a causal explanation that the client, due to their altered neurochemical state, cannot provide. It can also be perceived as challenging the reality of the client's experience, which invalidates their feelings and can damage the therapeutic relationship. This is not a therapeutic approach.
Choice C rationale
This redirects the conversation away from the client's immediate distress and the core issue of their hallucinations. While therapy is part of treatment, it may not be appropriate at this moment of crisis. The nurse’s priority is to first assess the immediate risk and support the client's immediate needs, before introducing another activity.
Choice D rationale
Asking about medication adherence can be perceived as accusatory and may cause the client to become defensive. While medication non-adherence can contribute to symptom exacerbation, the immediate priority is to assess the current risk level posed by the hallucinations, not to lecture the client about medication. This question is not therapeutic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Giving a new sibling plenty of "alone time" with a preschooler is a misconception and can cause increased feelings of resentment and jealousy. A preschool-age child may not understand why they are being left alone with the new baby, and it can be a source of stress. It is more effective to involve the older child in the care of the baby and to ensure the older child receives dedicated one-on-one time with a parent to feel valued and loved.
Choice B rationale
A common strategy to help a preschooler adjust to a new sibling is to give them a gift from the new baby. This gesture helps the older child associate the new baby with a positive experience rather than a negative one. It makes the older child feel special and included, reducing feelings of displacement or jealousy. It is a simple way to foster a sense of connection and warmth between the siblings.
Choice C rationale
Holding the new baby when the older child first meets them can cause the older child to feel excluded and jealous. This action may inadvertently create a sense of competition for the parent's attention. A better approach is for one parent to hold the baby while the other parent holds the older child, or for the baby to be in a bassinet or held by another family member, allowing the preschooler to have uninterrupted attention from the parent.
Choice D rationale
While meeting a new sibling at home can be beneficial, the most crucial factor is how the meeting is structured, not just the location. The location is less important than ensuring the older child feels included and not replaced. The nurse's suggestion should focus on strategies to manage the preschooler's feelings of jealousy and displacement, such as giving them a gift, rather than on the meeting's location, which is a secondary consideration
Correct Answer is D
Explanation
Choice A rationale
Dark spots or floaters in vision are not a typical post-operative finding for cataract removal. They are more commonly associated with retinal detachment, which is a rare but serious complication. The client should be instructed to report this to the provider immediately.
Choice B rationale
Bruising of the eyelids is not a normal or expected outcome after cataract surgery. The procedure is typically performed with a small incision and does not cause significant trauma to the surrounding tissues, making bruising an uncommon occurrence.
Choice C rationale
Cataract surgery is almost always performed using a local anesthetic, not general anesthesia. A local anesthetic is administered to numb the eye and surrounding area, allowing the client to remain awake and aware during the procedure while feeling no pain.
Choice D rationale
The fundamental principle of cataract surgery is the removal of the clouded, opaque lens and its replacement with a clear, artificial intraocular lens (IOL). This is the definitive treatment for cataracts, restoring visual clarity and function to the eye. *.
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