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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A: "Assess the client's need for assistance with ADLS."

Choice A rationale:

Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.

Choice B rationale:

Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.

Choice C rationale:

Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.

Choice D rationale:

Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.

A. A child who has a BMI indicating obesity. B. A child who uses the call light frequently. C. A child who has frequent visitors. D. A child whose parents answer questions for the child.

Correct Answer is D

Explanation

The correct answer is choice D. A child whose parents answer questions for the child.

Choice A rationale:A child with a BMI indicating obesity is not necessarily a sign of abuse. Obesity can result from various factors, including genetics, diet, and lifestyle. While it is important to address obesity for the child’s health, it does not directly indicate abuse.

Choice B rationale:A child who uses the call light frequently may be seeking attention or reassurance, but this behavior alone does not indicate abuse. Frequent use of the call light can be due to anxiety, fear, or a need for comfort, which can be addressed through appropriate nursing care and support.

Choice C rationale:A child who has frequent visitors is generally seen as having a strong support system. Frequent visits from family and friends usually indicate that the child is well-cared for and loved. This is not typically a sign of abuse.

Choice D rationale:A child whose parents answer questions for the child can be a red flag for abuse. This behavior may indicate that the parents are controlling and do not allow the child to speak for themselves, which can be a sign of emotional or psychological abuse. It is important for healthcare providers to observe interactions between the child and parents and assess for any signs of coercion or control.

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A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client newly admitted with major depressive disorder. After ensuring safety, which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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