A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?
"Let's take a walk outside to see if the voices you are hearing will stop."
"Can you listen to me instead of the voices you are hearing?"
"Are the voices you are hearing telling you to hurt yourself or someone else?"
"I know that the voices are real to you, but I do not hear them."
The Correct Answer is C
The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B. Location of the identification tag on the client's body
Rationale: The nurse should document the location of the identification tag on the client's body to ensure proper identification and prevent errors or mix-ups during transport or autopsy. The last set of vital signs, the copy of advance directives, and the cause of death are not part of the postmortem documentation but rather part of the medical record or death certificate.
Correct Answer is D
Explanation
Choice A reason:
Being honest with the parents of a child about the need to report suspected abuse is not the correct option. This option involves honesty and ethical responsibility but does not pertain to the fair distribution of resources or benefits.
Choice B reason
Keeping a promise to visit with a client who is housebound after the delivery of care is not the appropriate option. While keeping promises is an ethical principle, it is not related to the fair distribution of resources or benefits.
Choice C reason:
Accepting the decision of an older adult client to live alone in her home is not the correct option. Respecting a client's autonomy and right to make decisions about their living arrangements is an ethical principle, but it is not directly related to distributive justice.
Choice D reason:
The ethical principle of distributive justice is about fair and equitable distribution of resources and benefits within a society or group. It emphasizes providing equal access to services and resources to all individuals, especially those who are vulnerable or marginalized. In this context, the nurse demonstrates distributive justice by ensuring that a homeless client receives preventive medical care, which means they are being provided with necessary health resources and services that might otherwise be challenging for them to access due to their disadvantaged situation.
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