A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply?
A. "Did you take your medicine this morning?"
B. "You are not going to hell. You are a good person."
C. "I'm sure the voices sound scary. I don't hear any voices speaking."
D. "The devil only talks to people who are receptive to his influence."
C
The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination.
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The client is perspiring, has an increase in pulse and blood pressure, and states, "I am so worried about this operation I can't think straight." What is the most appropriate nursing diagnosis for this client?
a. Ineffective individual coping b. Anxiety c. Powerlessness d. Impaired adjustment
A patient who has been hospitalized for 2 days remains anxious and continues to be preoccupied with paranoid delusions. What intervention will best help the patient focus less on the delusions?
a. Schedule time for the patient to read and listen to music. b. Plan activities that require physical skills and constructive use of time. c. Begin planning for discharge by engaging the patient in psychoeducation. d. Discuss personal goals related to improved socialization with the patient.
A child has a history of hypoparathyroidism. While assessing the child, a nurse would expect to find:
1. A short, thick neck for a girl. 2. A malnourished child. 3. A small-statured boy. 4. A tall-statured girl.
Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He's jaundiced and reports weakness. Which intervention will you include in his care?
A. Regular exercise B. A low-protein diet. C. Allow patient to select his meals. D. Rest period after small, frequent meals.