a client says i hear a man speaking from the corner of the room do you hear him too which response is best

NCLEX-RN

NCLEX Psychosocial Questions

1. A client says, 'I hear a man speaking from the corner of the room. Do you hear him, too?' Which response is best?

A. What is he saying to you? Does it make any sense?
B. Yes, I hear him. What do you think he is saying?
C. No one is in the corner of the room. Can't you see that?
D. No, I don't hear him, but that must be upsetting for you.

Correct answer: D

Rationale: The best response is D: 'No, I don't hear him, but that must be upsetting for you.' This response acknowledges the client's experience without validating the hallucination. The nurse expresses empathy by acknowledging the client's feelings ('that must be upsetting for you'), showing understanding and support. Choice A focuses on the content of the hallucination, which may inadvertently reinforce the delusion. Choice B validates the hallucination by agreeing that the nurse also hears the man. Choice C denies the client's experience and can lead to further distress by invalidating their perception.

2. Which risk factor for suicide is considered the most lethal?

A. History of alcohol and drug abuse
B. Previous high-lethality suicide attempts
C. Recent withdrawal from friends
D. Disturbance of family dynamics

Correct answer: B

Rationale: The correct answer is 'Previous high-lethality suicide attempts.' This is the most lethal risk factor as it indicates that the individual has previously attempted suicide in a manner that could lead to death. This history increases the likelihood of future attempts. While substance abuse, like alcohol and drug use, is a significant risk factor for suicide, it is not considered the most lethal. Withdrawal from friends or social isolation can contribute to suicide risk but is not as directly deadly as high-lethality attempts. Disturbance of family dynamics can also be a stressor but does not represent the immediate lethality associated with a history of high-lethality suicide attempts.

3. Which of the following is a true statement about palliative care?

A. The goal of palliative care is to provide end-of-life care for a client as they transition toward death.
B. Palliative care provides comfort and support for those who may have a terminal illness.
C. Palliative care provides resources for funeral arrangements after death.
D. Palliative care is a support network for family and friends after the death of a loved one.

Correct answer: B

Rationale: Palliative care is a type of care that focuses on providing support and comfort to individuals who may have a terminal illness or severe symptoms. It aims to improve the quality of life for both the individual receiving care and their family. While it can be provided in various settings, including hospitals, homes, or specialized facilities, the primary focus is on symptom management and addressing the physical, emotional, and spiritual needs of the individual. Choice A is incorrect because palliative care is not solely limited to end-of-life care but also includes managing symptoms and improving quality of life. Choice C is incorrect as palliative care is focused on providing care and support during the individual's life, not on funeral arrangements after death. Choice D is incorrect as palliative care is primarily directed towards the individual receiving care, although it may also provide support to their family and friends during the care process.

4. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

A. How will this affect your present sexual activity?
B. How active is your current sex life?
C. How has your sex life changed as you have become older?
D. Tell me about your sexual needs as an older adult.

Correct answer: A

Rationale: The best response in this scenario is option A, 'How will this affect your present sexual activity?' This response directly addresses the client's concern and allows them to express their thoughts and feelings. Option B does not directly address the client's worry about the medication's side effect. Options C and D deviate from the client's immediate concern and are not as relevant in this situation.

5. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
D. Ask the client's family to co-sign the operative permit.

Correct answer: B

Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.