A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?
Ask the client direct questions about the hallucination.
Act to the client as if the hallucination is real.
Tell the client to go to their room and they should go away.
Instruct the client to argue with the voices that are a part of the hallucination.
The Correct Answer is A
The correct answer is choice A. Ask the client direct questions about the hallucination.
Choice A rationale:
Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.
Choice B rationale:
Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.
Choice C rationale:
Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.
Choice D rationale:
Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: Continuous worry about the undiagnosed presence of an illness.
Choice A rationale:
Sudden unexplained loss of peripheral sensation is not typically associated with illness anxiety disorder. This symptom may be indicative of a neurological condition and would require further medical evaluation to determine the cause.
Choice B rationale:
Obsession over a fictitious defect in physical appearance is more characteristic of body dysmorphic disorder, not illness anxiety disorder. Individuals with body dysmorphic disorder are preoccupied with one or more perceived defects or flaws in their physical appearance, which are not observable or appear slight to others.
Choice C rationale:
Having prior physical health followed by the need for two surgeries within the last three months does not necessarily indicate illness anxiety disorder. This choice does not provide enough context to link it to illness anxiety disorder, as it could be related to many other health conditions.
Choice D rationale:
Continuous worry about the undiagnosed presence of an illness is a key finding in illness anxiety disorder. Individuals with this disorder are excessively concerned with and preoccupied by the belief that they have, or are in danger of developing, a serious undiagnosed illness despite medical reassurance.
Correct Answer is C
Explanation
Choice A rationale:
Approaching the client frequently throughout the day for brief interactions might exacerbate the client's suspiciousness and discomfort. Individuals who are extremely suspicious may interpret frequent approaches as intrusive or manipulative, leading to increased agitation or withdrawal.
Choice B rationale:
Disclosing personal information to the client in an attempt to demonstrate approachability is not recommended. Sharing personal information can blur professional boundaries and may not necessarily address the client's suspicion. It's important to build trust gradually through consistent, respectful, and professional interactions.
Choice C rationale:
Adopting a neutral attitude when providing care is appropriate because it helps create a non-threatening environment. Individuals who are suspicious may interpret overly friendly or emotionally charged behavior as insincere or manipulative. A neutral and respectful approach allows the client to feel more comfortable and safe in the nurse's presence.
Choice D rationale:
Waiting for the client to initiate interaction may not be effective in establishing a therapeutic relationship. Extremely suspicious clients might be hesitant to initiate interactions due to their mistrust. Nurses should take the initiative to approach clients with suspicion in a respectful and neutral manner to gradually build rapport and trust.
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