Which hallucination necessitates the nurse to implement safety measures? The patient says.

The voices are telling me to harm myself

I hear Voices

I see birds flying in the room

The voices don't stop and continue all day

Answer and Explanation

The Correct Answer is A

A. The voices are telling me to harm myself: This statement indicates command hallucinations with a potential for harm. It suggests that the patient is receiving directives to harm themselves, which poses an immediate safety concern. Implementing safety measures, such as close monitoring, removal of harmful objects, and involving appropriate professionals, is essential to protect the patient from self-harm.

B. I hear voices: While hearing voices (auditory hallucinations) is a symptom that requires assessment and intervention, the nature of the voices is crucial in determining the level of risk. This statement, on its own, does not provide information about the content or potential harm associated with the voices.

C. I see birds flying in the room: This statement describes a visual hallucination, which, while potentially distressing, does not necessarily pose an immediate safety risk to the patient or others. Visual hallucinations may be less likely to necessitate immediate safety measures compared to command hallucinations.

D. The voices don't stop and continue all day: This statement suggests persistent auditory hallucinations, but without information about the content of the voices, it does not specifically indicate a risk of harm. While it may be distressing for the patient, the urgency for safety measures depends on the nature of the auditory content.

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Correct Answer is B

Explanation

A. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment): This statement is inaccurate. There is substantial evidence supporting the interaction between nature (biology and genetics) and nurture (environment) in the development of mental health conditions, including depression.

B. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors: This is the correct answer. It acknowledges the role of medications in addressing chemical imbalances but also emphasizes the importance of environmental and interpersonal factors in influencing biological factors. This response aligns with a biopsychosocial model of understanding mental health.

C. Because biological factors are the sole cause of depression, medications will improve your mood: This statement oversimplifies the complex etiology of depression. Depression is a multifactorial condition influenced by biological, psychological, and environmental factors. Medications may be part of the treatment, but they are not the sole solution.

D. Environmental factors have been shown to exert the most influence in the development of depression: This statement is also incorrect. Depression is influenced by a combination of biological, psychological, and environmental factors. No single factor is solely responsible for the development of depression.

A. A nurse asks a client if they have any cultural beliefs the nurse needs to be aware of B. A nurse tells a client about the nurse's own cultural background. C. A nurse observes a client's actions and reports they do not see any cultural practices D. A nurse checks a client's chart for any notes on culture

Correct Answer is A

Explanation

A. A nurse asks a client if they have any cultural beliefs the nurse needs to be aware of: This example demonstrates cultural competence as the nurse is actively seeking information about the client's cultural beliefs, practices, and preferences. It reflects an understanding that cultural factors can influence healthcare and the client-nurse relationship.

B. A nurse tells a client about the nurse's own cultural background: While sharing cultural information can be a part of building rapport, the focus of cultural competence is on understanding and respecting the client's cultural background, not necessarily sharing the nurse's own cultural background.

C. A nurse observes a client's actions and reports they do not see any cultural practices: This approach is limited, as cultural practices may not always be visible or evident in a clinical setting. Cultural competence involves actively seeking information from the client rather than making assumptions based on observations.

D. A nurse checks a client's chart for any notes on culture: While reviewing a client's chart for cultural information is part of cultural competence, it is not a complete approach. Direct communication with the client about their cultural beliefs and preferences is essential for a comprehensive understanding.

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Which hallucination necessitates the nurse to implement safety measures? The patient says.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

depressed client states. I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again. Which nursing response is appropriate?

Correct Answer is B

Explanation

A nurse is describing the concept of cultural competence to a newly licensed nurse. Which of the following examples should the nurse include?

Correct Answer is A

Explanation

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other Infected people. Which problem is evident?

A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

What is being assessed when a nurse asks a client to identify name date, residential address, and situation?

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid: benztropine (Cogentin), 1 mg prn: and zolpidem (Ambien). 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?