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. Both fontanels show molding. Molding is seen immediately after birth due to the passage through the birth canal and should not be present at 8 months.
B. The posterior fontanel is open. The posterior fontanel usually closes by 2 to 3 months of age.
C. For an 8-month-old infant, it is normal for the anterior fontanel to still be open. It typically closes between 12 to 18 months of age.
D. Both fontanels are the same size. The anterior and posterior fontanels are naturally different sizes; the anterior is larger.

A. "I will avoid using my microwave oven at home because of the ICD." B. "I will wear loose clothing over my ICD." C. "I can hold my cell phone on the same side of my body as the ICD." D. "I will soak in the tub rather than showering."

Correct Answer is B

Explanation

A. Modern ICDs are designed to withstand interference from household appliances like microwaves.
B. Wearing loose clothing over the implant site can help avoid irritation and discomfort around the ICD.
C. It is recommended to keep cell phones at least six inches away from the ICD to avoid potential electromagnetic interference.
D. There is no general restriction against showering with an ICD; precautions mainly focus on the period immediately after implantation.

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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

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