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?
"Why do you think you are hearing the voices?
"What are the voices telling you to do?"
you need to tell the voices to leave you alone."
"You need to understand that there are no voices.
The Correct Answer is B
A. "Why do you think you are hearing the voices?" This question may come across as confrontational and might make the client defensive. It's better to focus on the content of the hallucinations rather than questioning the client's perception.
B. "What are the voices telling you to do?"
This response is appropriate because it acknowledges the client's experience, shows empathy, and encourages the client to express their thoughts and feelings. It is important to gather more information about the content of the hallucinations and delusions to understand the client's perception of reality.
C. "You need to tell the voices to leave you alone." This response oversimplifies the experience of hallucinations and may not be helpful. Telling the client to dismiss the voices is unlikely to be effective and may lead to frustration.
D. "You need to understand that there are no voices." Denying the client's experience is not therapeutic. It's essential to validate the client's feelings and explore their subjective experience rather than dismissing it outright.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation:
A. While exercise can be beneficial for promoting sleep, suggesting it right before bedtime may not be the most practical advice, as vigorous exercise close to bedtime can sometimes have the opposite effect.
B. "Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep?"
This response acknowledges the potential issue with using alcohol as a sleep aid and opens the door for further discussion about alternative methods to promote better sleep. Alcohol can disrupt sleep patterns and lead to dependency, so it's important for the nurse to address this concern and explore healthier sleep-promoting strategies.
C. Encouraging the use of alcohol as a way to "take the edge off" is not the best approach, as it may reinforce the client's reliance on alcohol for sleep, which can lead to dependency and other health issues.
D. Suggesting that the client speak with their provider about prescribing a sedative should not be the initial response. It's essential to explore non-pharmacological interventions and lifestyle changes before considering medications, especially sedatives, due to the potential for dependence and side effects.
Correct Answer is B
Explanation
A. Dental caries is not a specific complication commonly associated with heroin use. Dental issues may result from other substances or lifestyle factors.
B. Perforation of the nasal septum is a complication associated with the intranasal use of heroin. Chronic snorting or sniffing of heroin can damage the nasal septum, leading to a perforation.
C. Permanent effects on short-term memory loss are more commonly associated with the use of substances like cannabis or certain hallucinogens. Heroin use is not typically linked to permanent effects on short-term memory.
D. Pancreatitis is not a commonly reported complication of heroin use. Pancreatitis is more commonly associated with alcohol use disorder and gallstone-related issues.
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