A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?

“I know you hear the voices, but I do not.”

“How often do you hear the voices?”

“What are the voices telling you?”

“The voices are part of your illness.”

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.

Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.

Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.

Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.

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Correct Answer is D

Explanation

Choice A rationale:

Shellfish is generally safe for clients taking MAOIs. However, it's important to ensure shellfish is fresh and properly refrigerated to avoid tyramine buildup due to spoilage.

Some individuals with shellfish allergies may need to avoid it regardless of MAOI use.

Choice B rationale:

Milk and milk products are typically safe for clients taking MAOIs.

However, some aged cheeses, such as cheddar, Swiss, and Parmesan, can contain high levels of tyramine and should be avoided.

Choice C rationale:

Canned tuna is generally safe for clients taking MAOIs.

However, it's essential to check labels carefully, as some brands may contain added tyramine-rich ingredients like soy sauce or fermented flavorings.

Choice D rationale:

Aged cheeses contain high levels of tyramine, an amino acid that can interact with MAOIs and cause a hypertensive crisis.

This is a potentially life-threatening condition characterized by a sudden and severe increase in blood pressure.

It's crucial for clients taking MAOIs to avoid all aged cheeses, including cheddar, Swiss, Parmesan, blue cheese, feta, and others.

A. Encourage group activities B. Encourage short rest periods throughout the day C. Provide a stimulating environment D. Schedule daily seclusion times

Correct Answer is B

Explanation

Choice A rationale:

While group activities can be beneficial for some clients with bipolar disorder, they may not be appropriate during a manic phase. This is because group settings can be overstimulating and overwhelming for individuals experiencing mania. The increased activity and social interaction can exacerbate symptoms such as racing thoughts, pressured speech, and impulsivity.

It's crucial to prioritize calming activities and minimize external stimuli during manic episodes.

Choice C rationale:

Providing a stimulating environment is not recommended for clients in the manic phase of bipolar disorder. A stimulating environment can worsen symptoms of mania, such as:

Increased energy and activity levels

Racing thoughts

Impulsivity

Distractibility

Risk-taking behavior

Irritability

Aggression

Decreased need for sleep Grandiose thinking

Poor judgment

Hypersexuality

A calm and structured environment is more conducive to managing manic symptoms.

Choice D rationale:

Scheduling daily seclusion times is not a standard intervention for clients in the manic phase of bipolar disorder. Seclusion is a restrictive intervention that should only be used as a last resort when a client is at risk of harming themselves or others. It's essential to explore less restrictive alternatives for managing manic symptoms, such as medication, therapy, and environmental modifications.

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A nurse is caring for a client who is experiencing auditory hallucinations. What should the nurse say first?

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Correct Answer is D

Explanation

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Correct Answer is B

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A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?