A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Placing the client on one-on-one observation while monitoring for suicidal ideations

Conducting 15minute checks to ensure safety

Encouraging the client to verbalize feelings related to suicide

Completing a room search to ensure there are no harmful objects available to the client.

Answer and Explanation

The Correct Answer is A

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

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Correct Answer is C

Explanation

A. While understanding precipitating factors is important, it is not the immediate priority when the client is actively experiencing hallucinations.
B. Distracting the client may not address the underlying cause of the hallucinations, which should be the priority.
C. Determining the content of the hallucinations can provide important information for assessment and intervention.
D. Dismissing the client's experience can be alienating and unhelpful.

A. Sedation and muscle stiffness B. Sweating, nausea, and diarrhea C. Mild fever, sore throat, and skin rash D. Headache, watery eyes, and runny nose

Correct Answer is A

Explanation

A) Correct. Haloperidol, a first-generation antipsychotic, commonly causes side effects like sedation (drowsiness) and extrapyramidal symptoms, including muscle stiffness.

B) Incorrect. Sweating, nausea, and diarrhea are not typically associated with haloperidol.
C) Incorrect. Mild fever, sore throat, and skin rash are not common side effects of haloperidol.
D) Incorrect. Headache, watery eyes, and runny nose are not common side effects of haloperidol.

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A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What intervention is a priority when the client is experiencing auditory hallucinations?

Correct Answer is C

Explanation

When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the client?

Correct Answer is A

Explanation

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