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 A

Explanation

A: Swallowing ability is crucial because ALS often leads to dysphagia, which can cause weight loss due to difficulty eating and the risk of aspiration.
B: Changes in appetite are important but secondary to physical ability to eat safely.

C: While knowing about prescribed medications is necessary, it does not directly address the issue of weight loss as critically as swallowing ability.
D: Fluid intake is important but the priority is assessing the ability to swallow safely, which directly impacts nutritional status.

A. Monitor the child's cardiac status. B. Give scheduled doses of acetaminophen every 6 hr. C. Provide stimulation with children of the same age in the play room. D. Administer antibiotics via intermittent IV bolus for 24 hr.

Correct Answer is A

Explanation

A. Kawasaki disease involves inflammation of the blood vessels and can lead to serious cardiac complications, including coronary artery aneurysms. Monitoring cardiac status is essential to detect and manage these risks.
B. While managing fever is a part of treating Kawasaki disease, acetaminophen is typically used as needed rather than on a strict schedule unless fever is persistent.
C. During the acute phase of Kawasaki disease, children often feel very irritable and unwell; large group activities may be overwhelming and inappropriate.
D. Kawasaki disease is not caused by a bacterial infection, and antibiotics are not part of the treatment. Instead, treatment usually involves high-dose aspirin and intravenous immunoglobulin.

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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?

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