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 ["A","C","D"]
Explanation
Choice A rationale:
Impulsive behaviors, such as sudden excessive spending, risky sexual encounters, or reckless driving, are common manifestations of manic behavior in individuals with bipolar disorder. These behaviors can result from the heightened energy and impulsivity associated with a manic episode.
Choice B rationale:
Dressing in black or grey clothing is not indicative of manic behavior. Mania is characterized by heightened mood, excessive energy, and impulsivity, rather than specific clothing choices.
Choice C rationale:
Talking in rapid, continuous speech, also known as pressured speech, is a classic symptom of manic episodes. Individuals may talk rapidly, switch topics frequently, and have difficulty allowing others to interject or participate in the conversation.
Choice D rationale:
Interacting with others in a flirtatious way can be a manifestation of manic behavior. During manic episodes, individuals may exhibit increased sociability, reduced inhibitions, and engage in behaviors that are out of character, including flirtatious interactions.
Choice E rationale:
Sleeping for long periods of time is not consistent with manic behavior. Manic episodes are often associated with decreased need for sleep, and individuals may experience insomnia or only require minimal sleep during these episodes.
Correct Answer is B
Explanation
The correct answer is choice B. A room containing personal belongings.
Choice A rationale:
Similar to the rationale provided for , a room without a window would not provide the necessary sensory input and connection to the outside world. Natural light and visual stimuli are important for maintaining a sense of time and orientation.
Choice B rationale:
A room containing personal belongings is the correct answer for the same reasons as mentioned in the previous question. Familiar items can provide comfort and reduce feelings of agitation in cognitively impaired individuals.
Choice C rationale:
Once again, a room adjacent to the nursing station could expose the client to unnecessary noise and activity, potentially causing distress and hindering the therapeutic environment required for cognitively impaired individuals.
Choice D rationale:
Dim lighting can contribute to disorientation and confusion. Adequate lighting helps individuals perceive their surroundings and reduces the risk of accidents.
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