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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:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.

A. Monitor the client closely to prevent self-mutilation. B. Give positive feedback when the client is assertive with staff or clients. C. Discourage flamboyant or seductive behaviors. D. Set limits to prevent exploitation of other clients.

Correct Answer is B

Explanation

Choice A rationale:

Monitoring the client closely to prevent self-mutilation is more associated with self-harm disorders rather than dependent personality disorder.

Choice B rationale:

Giving positive feedback when the client is assertive with staff or clients can encourage independence and confidence.

Choice C rationale:

Discouraging flamboyant or seductive behaviors is more related to histrionic personality disorder.

Choice D rationale:

Setting limits to prevent exploitation of other clients is more associated with antisocial personality disorder.

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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 asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.).

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A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder.(Select all that apply.).

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

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?.