A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

"You need to tell the voices to leave you alone.”

"You need to understand that there are no voices.”

"What are the voices telling you to do?”

"Why do you think you are hearing the voices?”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

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Correct Answer is C

Explanation

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

A. Request a mental health consult. B. Provide a structured environment for the client. C. Assess client's nutritional status. D. Plan a therapeutic diet for the client.

Correct Answer is A

Explanation

The correct answer is choice A: Request a mental health consult.

Choice A rationale:

Requesting a mental health consult is the first priority in this situation. The client's significant weight loss, distorted body image, and belief that she is fat suggest potential body dysmorphic disorder, eating disorder, or other psychological concerns. It's crucial to address these underlying issues before focusing on other aspects of care.

Choice B rationale:

Providing a structured environment can be beneficial, but it might not address the root cause of the client's psychological distress and distorted body image.

Choice C rationale:

Assessing the client's nutritional status is important to understand the physical impact of the weight loss, but the urgent need here is to address the client's psychological well-being and distorted self-perception.

Choice D rationale:

Planning a therapeutic diet for the client is essential, but it should not be the first priority. The client's belief that she is fat and her significant weight loss indicate deeper psychological issues that require immediate attention. Without addressing these psychological concerns, focusing solely on a diet plan might exacerbate her distorted body image and eating behaviors.

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A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is A

Explanation

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