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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While encouraging decision-making can be empowering for some individuals with depression, it may not be appropriate for those with severe depressive disorder.
Individuals with severe depression often experience significant anhedonia (loss of interest in activities), fatigue, and difficulty concentrating, which can make decision-making overwhelming and even worsen their symptoms.
It's important to assess the client's individual level of functioning and decision-making capacity before implementing this intervention.
Choice C rationale:
Providing a selection of activities can be helpful, but it's crucial to tailor the activities to the client's interests and energy level.
Offering too many choices or activities that are too demanding can be counterproductive.
It's essential to collaborate with the client to identify activities that are meaningful and achievable, and to gradually increase the level of activity as tolerated.
Choice D rationale:
Playing a game of chess can be a stimulating and enjoyable activity, but it may not be appropriate for all clients with severe depression.
Chess requires cognitive focus and strategic thinking, which can be challenging for individuals experiencing cognitive impairment or fatigue associated with depression.
It's important to assess the client's cognitive abilities and interests before suggesting this activity.
Rationale for the correct answer, B:
Spending time with the client offers several benefits:
Conveys caring and support: It demonstrates to the client that they are not alone and that someone cares about their wellbeing.
Provides opportunities for therapeutic communication: Spending time together allows for meaningful conversations, which can help the client express their feelings, concerns, and experiences.
Facilitates observation and assessment: The nurse can observe the client's mood, behavior, and interactions, which can inform treatment planning and evaluation.
Promotes engagement and participation: Spending time with the client can encourage them to engage in other therapeutic activities and interventions.
Builds rapport and trust: Developing a strong therapeutic relationship is essential for effective treatment of depression.
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.
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