a client states i am the only one who can hear voices which is the nurses best response
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?

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.

2. Which characteristic presents the greatest risk for injury to others in a patient diagnosed with schizophrenia?

Correct answer: D

Rationale: Paranoia in patients with schizophrenia can lead to aggressive behaviors, including violence, which poses a significant risk of injury to others. Individuals experiencing paranoia may perceive others as threats and act defensively or aggressively in response, increasing the likelihood of harm to those around them.

3. Which of the following characteristics is not a feature of borderline personality disorder?

Correct answer: D

Rationale: Borderline personality disorder is characterized by an intense fear of abandonment, unstable relationships, impulsivity, and chronic feelings of emptiness. Grandiosity, which involves an inflated sense of self-importance, is typically associated with narcissistic personality disorder rather than borderline personality disorder.

4. Which intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia?

Correct answer: A

Rationale: Screening males aged 15 to 25 for early symptoms of schizophrenia is a well-chosen intervention as this age group is at a higher risk for developing the condition. Early identification can lead to timely treatment and better outcomes, making this intervention particularly effective in addressing the population at risk for schizophrenia.

5. A client diagnosed with borderline personality disorder tells the nurse, 'You are the only one who understands me. The other nurses don't care about me.' Which of the following responses should the nurse make?

Correct answer: B

Rationale: The correct response is to acknowledge the client's feelings and provide support while also emphasizing that all staff members care about the client's well-being. Choice A does not acknowledge the client's emotions and may come across as dismissive. Choice C invalidates the client's feelings and may make the client feel misunderstood. Choice D minimizes the client's emotions, which can lead to a breakdown in therapeutic communication. Therefore, option B is the most appropriate response as it validates the client's feelings while reinforcing the idea that the entire healthcare team is supportive.

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