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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

To calculate the percentage of weight loss, we can use the formula:

Percentage of weight loss = (Weight loss / Original weight) * 100

Given that the client lost 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb), we can substitute these values into the formula:

Percentage of weight loss = (6.8 kg / 90.7 kg) * 100 Percentage of weight loss = 0.0749 * 100 Percentage of weight loss = 7.49%

The percentage of weight loss is approximately 7.49%.

Since none of the provided answer options exactly match this calculated percentage, the closest option is:

So, the nurse should identify the weight loss as approximately 7.5%.

A. Shrimp salad B. Pulled-pork sandwich C. Clam chowder D. Roasted salmon

Correct Answer is D

Explanation

The correct answer is D. Roasted salmon. A kosher diet is based on Jewish dietary laws that prohibit certain foods and combinations of foods. Some of these rules include avoiding pork, and shellfish, and mixing meat and dairy products. Therefore, shrimp salad, pulled pork sandwich, and clam chowder are all non-kosher menu items that should be avoided by a

client who follows a kosher diet. Roasted salmon is a kosher menu item that can be included on the tray, as long as it is not served with any dairy products or non-kosher ingredients.

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A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

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Naxlex Comprehensive Predictor Exams

A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

Correct Answer is A

Explanation

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

Correct Answer is D

Explanation

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