Nokea
A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?
- A. Tell me more about these voices.
- B. Let's explore these voices together.
- C. How long have you been hearing these voices?
- D. Have you told anyone else about these voices?
Correct Answer: A
Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.
You may also like to solve these questions
A client with schizophrenia is experiencing delusions. Which intervention should the nurse implement to address this symptom?
- A. Encourage the client to ignore the delusions.
- B. Provide reality-based feedback to the client.
- C. Distract the client from the delusions.
- D. Encourage the client to discuss the delusions.
Correct Answer: B
Rationale: When a client with schizophrenia is experiencing delusions, providing reality-based feedback is considered an effective intervention to address this symptom. This approach helps the client differentiate between what is real and what is not real, assisting them in managing their delusions and promoting their overall well-being. Choice A is incorrect because ignoring the delusions does not help the client in distinguishing reality from delusions. Choice C is incorrect as distraction may only provide temporary relief but does not address the underlying issue. Choice D is incorrect because encouraging the client to discuss the delusions may reinforce or intensify them rather than help in managing them effectively.
In a client with obsessive-compulsive disorder (OCD) undergoing cognitive-behavioral therapy, which outcome indicates that the therapy is effective?
- A. The client reports a decrease in the frequency of compulsive behaviors.
- B. The client reports a decrease in the intensity of obsessive thoughts.
- C. The client reports an improvement in overall mood.
- D. The client reports an improvement in sleep patterns.
Correct Answer: A
Rationale: In clients with OCD undergoing cognitive-behavioral therapy, a decrease in the frequency of compulsive behaviors is a key indicator of treatment effectiveness. This reduction signifies progress in managing and controlling the compulsions associated with OCD, which is a primary goal of the therapy. Choices B, C, and D may also be positive outcomes of therapy, but the most critical aspect in treating OCD with cognitive-behavioral therapy is targeting and reducing the frequency of compulsive behaviors.
A client with bipolar disorder is experiencing a depressive episode. Which nursing intervention is most appropriate?
- A. Encourage the client to avoid physical activity.
- B. Encourage the client to engage in social activities.
- C. Encourage the client to participate in group therapy.
- D. Encourage the client to set realistic goals.
Correct Answer: C
Rationale: Encouraging the client to participate in group therapy is the most appropriate nursing intervention for a client with bipolar disorder experiencing a depressive episode. Group therapy provides a supportive environment where the client can share experiences, learn coping strategies, and receive emotional support from peers and mental health professionals. It can help reduce feelings of isolation, improve social skills, and enhance overall well-being. Group therapy also promotes a sense of belonging and understanding, which are essential for individuals dealing with bipolar disorder and depressive symptoms. Choices A, B, and D are not the most appropriate interventions for a client experiencing a depressive episode in bipolar disorder. Encouraging the client to avoid physical activity may worsen their symptoms, promoting social activities may not address the underlying issues effectively, and setting goals may be overwhelming during a depressive episode.
A client with generalized anxiety disorder is prescribed buspirone. Which statement by the client indicates a need for further teaching?
- A. I can stop taking this medication once I feel less anxious.
- B. I should avoid drinking alcohol while taking this medication.
- C. It may take several weeks for this medication to take full effect.
- D. This medication can cause dependency.
Correct Answer: A
Rationale: The correct answer is A because it indicates a misunderstanding about buspirone. Buspirone should not be abruptly stopped, and patients should follow the prescribed regimen consistently. Stopping the medication without proper guidance can lead to adverse effects or a return of anxiety symptoms. Choices B, C, and D demonstrate an understanding of important aspects of buspirone therapy: avoiding alcohol due to interactions, being patient for the medication to reach full effectiveness, and being aware of the potential for dependency with this medication.
A nurse is assessing a client who has been diagnosed with persistent depressive disorder (dysthymia). Which of the following findings should the nurse expect?
- A. Episodes of hypomania
- B. Periods of elevated mood
- C. Lack of interest in activities
- D. Feelings of detachment from one's body
Correct Answer: C
Rationale: The correct finding the nurse should expect in a client diagnosed with persistent depressive disorder (dysthymia) is a lack of interest in activities. This disorder is characterized by a chronic depressive mood lasting for at least two years, alongside symptoms such as changes in appetite, fatigue, low self-esteem, and difficulty concentrating. Clients with dysthymia do not typically experience hypomania, periods of elevated mood, or feelings of detachment from one's body, which are more commonly associated with other mood disorders. Therefore, options A, B, and D are incorrect findings for a client with persistent depressive disorder.