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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Disulfiram should be taken each morning, and it is recommended to start it 48 hours after the last drink of alcohol to prevent a severe reaction. This helps establish a clear association between the medication and alcohol avoidance.
B. While taking disulfiram with water is generally advisable, the crucial aspect is the timing and the initial 48-hour abstinence period.
C. Taking the medication at bedtime or limiting alcohol to one ounce daily does not address the specific timing requirement for disulfiram initiation.
D. Beginning the medication immediately and taking it daily, regardless of alcohol consumption, may not establish the necessary 48-hour alcohol-free period before starting disulfiram.

A. Show the client the unit. B. Explain the nurse’s role to the client. C. Read the client his/her rights. D. Offer medication to the client.

Correct Answer is B

Explanation

A. Showing the client the unit may be overwhelming and not address the immediate need for communication and building rapport.
B. Explaining the nurse's role helps establish trust and provides the client with information about who is present and their purpose.
C. Reading the client his/her rights is important but may be premature and not as immediately relevant as establishing communication.
D. Offering medication should come after establishing communication and assessing the client's needs, as not all clients may require or be ready for medication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

Correct Answer is A

Explanation

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

Correct Answer is B

Explanation

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)