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A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?
- A. Act as if the hallucination is real.
- B. Instruct the client to argue with the voices that are a part of the hallucination.
- C. Ask the client direct questions about the hallucination.
- D. Tell the client that the hallucination is not a part of reality.
Correct Answer: C
Rationale: The correct answer is C - Ask the client direct questions about the hallucination. This approach helps the nurse understand the client's experience without validating or denying the hallucination. It shows empathy and promotes trust. Choice A would validate the hallucination, worsening the client's condition. Choice B could escalate the situation by encouraging confrontation with the voices. Choice D may cause the client to feel dismissed or judged. Asking direct questions (C) allows the nurse to gather information, assess the client's safety, and provide appropriate care.
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A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.
A nurse is speaking with a client experiencing anxiety. Which of the following responses is most therapeutic?
- A. "Most clients with anxiety benefit from lying down."
- B. "Come with me to an area where we can talk without interruption."
- C. "Providers usually recommend relaxation exercises for clients who are upset."
- D. "An antianxiety pill works best for situations like this."
Correct Answer: B
Rationale: The correct answer is B. Bringing the client to an area for uninterrupted conversation shows active listening and support. It promotes a safe space for the client to express feelings and reduces anxiety. Choice A is incorrect as it assumes all clients benefit from lying down, which may not be true. Choice C is incorrect because recommending relaxation exercises may not address the client's immediate needs. Choice D is incorrect as medication should not be the first response for managing anxiety without exploring other options first.
A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
- A. "Your husband is making really good progress."
- B. "Crying helps us let things out and we feel better."
- C. "Did your husband say something to upset you?"
- D. "Tell me what’s concerning you."
Correct Answer: D
Rationale: Encouraging the spouse to verbalize concerns supports therapeutic communication.
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Constipation
- C. Menorrhagia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Constipation. In anorexia nervosa, a lack of adequate nutrition intake can lead to decreased gastrointestinal motility, resulting in constipation. Tachycardia (A) is common due to the body's response to malnutrition. Menorrhagia (C) is unlikely as anorexia nervosa often leads to amenorrhea. Hyperkalemia (D) is less likely as potassium levels tend to be low due to decreased food intake.
A nurse is caring for a client who has an eating disorder. The nurse is practicing which of the following ethical concepts when the client refuses to drink a between-meal protein and calorie supplement?
- A. Autonomy
- B. Beneficence
- C. Veracity
- D. Fidelity
Correct Answer: A
Rationale: Respecting the client’s decision to refuse food aligns with the ethical principle of autonomy.