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    Rn ati comprehensive predictor 2023 proctored exam

    A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

    Explanation & Rationale

    A. "That can't be true. The only voices in this room are yours and mine.": This response dismisses the client’s experience and can invalidate their feelings, which is not therapeutic or supportive. B. "Do you recognize the voices as belonging to anyone you know?": While this question could gather more information, it might divert the focus from the client’s immediate feelings of fear and distress. C. "I understand the voices are frightening you, but I do not hear any voices.": This response validates the client's experience of fear and acknowledges their distress while also gently indicating that the nurse does not perceive the voices. It encourages open communication about the client’s feelings. D. "You shouldn't be afraid when you think the voices are telling you to hurt yourself.": This response is inappropriate as it minimizes the client’s feelings and does not address the seriousness of their statements about self-harm. It’s crucial to acknowledge their fear rather than dismissing it.

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