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A nurse is talking with a client who has 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?.

"What are the voices telling you to do?".

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

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

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

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Asking “What are the voices telling you to do?” shows empathy and concern without validating the hallucination.

Choice B rationale:

Asking “Why do you think you are hearing the voices?” might imply that the nurse is validating the hallucination.

Choice C rationale:

Telling the client “You need to understand that there are no voices.”. might make the client feel misunderstood.

Choice D rationale:

Telling the client “You need to tell the voices to leave you alone.”. is not recommended as it might validate the hallucination.

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Correct Answer is A

Explanation

Choice A rationale:

Extrapyramidal symptoms are a common adverse effect of haloperidol.

Choice B rationale:

Intractable hiccups are not typically associated with haloperidol.

Choice C rationale:

Fever is not a common side effect of haloperidol, but could indicate a serious condition like neuroleptic malignant syndrome.

Choice D rationale:

Excessive salivation is not typically a side effect of haloperidol.

A. Discourage clients from discussing the NSSH with friends. B. Early recognition is crucial to successful treatment. C. Recognize non-suicidal self-harm as an attention-seeking behavior. D. Ask the client why they do this as soon as possible.

Correct Answer is B

Explanation

Choice A rationale:

Discouraging clients from discussing NSSH with friends may not be beneficial. Open communication can provide support and understanding.

Choice B rationale:

Early recognition is crucial to successful treatment. Timely intervention can prevent the escalation of self-harm behaviors and facilitate recovery.

Choice C rationale:

Recognizing NSSH as an attention-seeking behavior can be a misconception. NSSI is a complex behavior often associated with various underlying issues like emotional distress.

Choice D rationale:

Asking the client why they do this as soon as possible may not always be helpful. The focus should be on understanding their feelings and providing support.

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A nurse is talking with a client who has 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 is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol?

Correct Answer is A

Explanation

A nurse is conducting an in-service for a group of newly licensed nurses about the interventions used for clients experiencing non-suicidal self-harm (NSSH). Which of the following should the nurse include?.

Correct Answer is B

Explanation

A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation. Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?

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A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

A nurse is talking with a client who has 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?.