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 C

Explanation

A. Using up to 40 nicotine lozenges per day is excessive and may lead to nicotine toxicity.

B. Substituting tobacco use with an electronic cigarette is not recommended due to potential health risks associated with vaping.
C. Nicotine replacement therapy, such as nicotine gum, should be used for a limited duration to avoid dependence. The nurse should educate the client to limit the use of nicotine gum to no more than 6 months to achieve smoking cessation goals effectively.
D. Using progressively larger nicotine patches is not a standard practice and may increase the risk of nicotine overdose.

A. Provide a cooling blanket. B. Monitor the client's cardiac rhythm. C. Administer 0.9% sodium chloride IV. D. Obtain the client's blood glucose.

Correct Answer is B

Explanation

A. Providing a cooling blanket may help reduce fever associated with a thyroid storm but is not the priority over monitoring the cardiac rhythm.
B. In a thyroid storm, the client is at risk for severe cardiovascular complications, including tachycardia, arrhythmias, and heart failure. Therefore, the nurse's priority action is to monitor the client's cardiac rhythm continuously to detect any abnormalities promptly and intervene as needed.
C. Administering 0.9% sodium chloride IV may be necessary to maintain fluid balance, but it's not the priority over cardiac monitoring.
D. Obtaining the client's blood glucose may be relevant but is not the priority in the acute management of a thyroid storm.

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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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Naxlex Comprehensive Predictor Exams

A nurse is discussing treatment options with a client who is experiencing nicotine withdrawal. Which of the following Information should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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