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
Choice A rationale:
Sweating is not an adverse effect commonly associated with buspirone (Buspar). While some side effects like dizziness, nausea, and headache might occur, sweating is not typically reported as a significant adverse effect of this medication.
Choice B rationale:
Decreased appetite is a potential adverse effect of buspirone (Buspar). However, it is not the most concerning in this context. Anxiety disorders like generalized anxiety disorder can lead to appetite changes, and while this should be monitored, it is not a priority compared to more severe adverse effects.
Choice C rationale:
Discolored urine is not a common adverse effect of buspirone (Buspar). Buspirone is primarily used to treat anxiety and does not usually cause changes in urine color. This effect is unrelated to the medication and likely has a different underlying cause.
Choice D rationale:
Hallucinations are a concerning adverse effect that should be reported to the provider. Hallucinations are not a typical side effect of buspirone and might indicate a more serious issue or an interaction with other medications. Reporting this symptom promptly is crucial to ensuring the client's safety and well-being.
Correct Answer is ["B","E"]
Explanation
Choice A rationale:
Monitoring vital signs throughout the day is essential for a client experiencing mania, but it is not a specific intervention related to managing the manic state. Mania is associated with high energy levels and hyperactivity, which can affect vital signs. However, this intervention does not directly address the core symptoms of mania.
Choice B rationale:
Maintaining an environment with low stimuli is crucial for managing a client experiencing mania. Manic individuals are often highly sensitive to external stimuli, and a low-stimulation environment helps reduce agitation and potential exacerbation of manic behaviors.
Choice C rationale:
Discouraging the client from taking a nap during the day is not a suitable intervention for managing mania. Sleep disturbances are common during manic episodes, and attempting to restrict daytime naps might increase restlessness and agitation.
Choice D rationale:
Weighing the client every 3 to 4 days is not a specific intervention for managing mania. Weight monitoring might be relevant in certain contexts, such as if the client's medication regimen is associated with weight changes, but it does not directly address the manifestations of mania.
Choice E rationale:
Offering nutritional foods to the client every 2 hours is an important intervention for managing mania. Manic individuals often engage in impulsive behaviors, including neglecting self-care such as eating. Providing regular and nutritious meals helps stabilize blood sugar levels and supports the body's energy demands during this hyperactive phase.
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