A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things.". Which of the following responses should the nurse make next?
a. "Do you recognize the voice you hear?'
b. "How long has this been happening?"
c. "Does what the voice tells you to do frighten you?"
d. "What is the voice telling you to do?"
D
Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The other queries are of lesser importance than identifying the command.
You might also like to view...
The client with heart failure has been ordered to receive a daily nitroglycerin transdermal patch. What action taken by the nurse would help avoid tolerance to the vasodilating effects of this medication?
A. Place an occlusive dressing over the patch. B. Remove the patch overnight. C. Rotate the skin site of nitroglycerin administration. D. Administer a larger loading dose before the initiation of therapy.
The nurse is demonstrating the Z-track injection technique to a nursing student on a patient who is receiving iron dextran. Which statement by the student indicates understanding of the teaching?
a. "This is necessary to prevent staining of the patient's skin." b. "This technique allows slower, more sustained absorption." c. "You may use the ventrogluteal site when using this method." d. "I should use a 27-gauge needle to minimize discomfort with this method."
The pancreas secretes:
a. Parathormone b. Epinephrine and norepinephrine c. Insulin d. Adrenocorticotropic hormone
A client is prescribed a calcium channel blocker for control of hypertension is now prescribed a beta blocker to control a fast ventricular rate. What should the nurse include in instructions regarding the medications?
1. Eat a high-fiber, low-carbohydrate diet. 2. Do not take this medication with grapefruit juice. 3. Maintain a daily exercise regimen. 4. Report irregular heart rate or shortness of breath to the health care provider.