The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

The voices you are hearing are not real

Let’s talk about the next time this happens

You need to be calm and focus on something else

You appear to be speaking with someone

None

Answer and Explanation

The Correct Answer is D

A. Telling the client that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

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Correct Answer is B

Explanation

A. Administering disulfiram is not the priority in the immediate care of a client with a closed head injury and elevated blood alcohol level. The focus should be on ensuring the client's safety and preventing complications related to the head injury.
B. Placing the client in a side-lying position with the head of the bed elevated is crucial to prevent aspiration and maintain airway patency in a client who is difficult to arouse due to alcohol intoxication.
C. Giving lorazepam for signs of withdrawal may be necessary but does not address the immediate risk of aspiration in a client with altered consciousness.
D. Providing thiamine and folate supplements is important for clients with alcohol use disorders, but the priority in this scenario is airway protection and preventing complications related to the head injury.

A. Sit in the chair next to the client. B. Listen to what the client is saying. C. Escort the client to his room. D. Administer a PRN sedative.

Correct Answer is B

Explanation

A. Sitting in the chair next to the client may be supportive but does not address the immediate concern of the client's behavior or hallucinations.
B. Listening to what the client is saying is crucial to understanding the content and nature of the auditory hallucinations, providing insight into the client's experience.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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