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?"
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Milk products can exacerbate symptoms of irritable bowel syndrome in some individuals, especially those with lactose intolerance, and are generally not recommended.
B. Foods sweetened with fructose corn syrup may exacerbate symptoms of irritable bowel syndrome in some individuals and are best avoided.
C. Gluten-containing foods may trigger symptoms in individuals with irritable bowel syndrome, particularly those with gluten sensitivity or celiac disease, and should be limited or avoided as appropriate.
D. Increasing intake of foods high in bran fiber can help regulate bowel movements and alleviate symptoms of constipation, which is often a concern for individuals with irritable bowel syndrome.
Correct Answer is A
Explanation
A. Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B. Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C. Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.
D. Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.
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