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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. "It will help you feel better if you talk about it." While talking can be therapeutic, pushing the client to talk when they're not ready may be counterproductive and increase their distress.

B. "Come on out and get involved with the game the other clients are playing." Encouraging the client to engage in activities may not be suitable when she is expressing a need for solitude and is not ready to participate.

C. "I'll stay with you for a few minutes."
This response reflects the nurse's willingness to provide support without pressuring the client to talk. It acknowledges the client's feelings and offers a comforting and nonintrusive presence. It respects the client's desire for solitude while still showing empathy and availability.

D. "I'll come back when you feel like talking." This response leaves the client alone, which may
be appropriate if that's what the client prefers. However, offering to stay for a few minutes communicates immediate support without pressure.

A. Blood pressure B. Lack of motivation C. Change in behaviour D. Lack of energy E. Withdrawn

Correct Answer is ["B","D","E"]

Explanation

The "3" findings that should indicate to the nurse that the client is experiencing negative symptoms related to their schizophrenia are:
B.Lack of motivation
D.Lack of energy
E.Withdrawn
Explanation:
Negative symptoms in schizophrenia involve deficits or reductions in normal emotional and behavioral functioning. In the provided nurse's notes:

Blood pressure: Blood pressure is not mentioned in the nurse's notes, and it is not directly indicative of negative symptoms in schizophrenia.

B. Lack of motivation: The client refusing to eat or drink, not engaging in conversation, and not wanting to go to therapy sessions are indicative of a lack of motivation, which is a negative symptom.

C. Change in behavior: While there is a change in behavior mentioned in the notes (refusing to eat or drink, not engaging in conversation), the specific behavioral changes described are more closely associated with negative symptoms. Negative symptoms involve a reduction or loss of normal functions.

D. Lack of energy: The client's slow movements and desire to sleep suggest a lack of energy, another negative symptom associated with schizophrenia.

E. Withdrawn: The client's withdrawal from social interaction, as evidenced by not engaging in conversation and wanting to sleep, is characteristic of withdrawal, which is a negative symptom.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has schizophrenia. Exhibits Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.

Correct Answer is ["B","D","E"]

Explanation

As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

A nurse is caring for a group of clients in a mental health facility. Which of the following clients recommend the physician or nurse practioner see first?

A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?