A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

"That can't be true. The only voices in this room are yours and mine."

"You shouldn't be afraid when you think the voices are telling you to hurt yourself."

"I understand the voices are frightening you, but I do not hear any voices."

"Do you recognize the voices as belonging to anyone you know?"

Answer and Explanation

The Correct Answer is C

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

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Correct Answer is D

Explanation

A: It's not the nurse's role to provide detailed information about the benefits of surgery on the informed consent form; this should be done by the provider.
B: Informing the client about their condition is primarily the provider's responsibility before obtaining consent.
C: The nurse should not be the one to explain the procedure; this is the provider's responsibility. The nurse ensures the client understands after the provider's explanation.
D: Confirming the client's signature is authentic is a crucial step for the nurse to ensure that the consent is valid and the client has indeed agreed to the procedure.

A. Direct statements to the interpreter. B. Speak in a normal voice at a natural pace. C. Pause in the middle of sentences. D. Use gestures when speaking with the client.

Correct Answer is B

Explanation

A. Directing statements to the interpreter rather than the client can create a communication barrier and undermine the client's autonomy and involvement in the conversation.
B. Speaking in a normal voice at a natural pace allows the interpreter to accurately convey the message to the client without feeling rushed or overwhelmed, facilitating effective communication.
C. Pausing in the middle of sentences can disrupt the flow of communication and make it difficult for the interpreter to accurately translate the message.
D. While gestures can complement verbal communication, relying solely on gestures may lead to misinterpretation or misunderstanding, especially if cultural differences exist between the nurse, client, and interpreter.

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A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is verifying a record of Informed consent for a client who is scheduled for surgery. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is B

Explanation

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