A nurse is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Choice A reason:
The statement "You should take a 2-hour nap during the afternoon" is not advisable. While short naps can be beneficial, long naps, especially those taken late in the day, can interfere with nighttime sleep by reducing sleep drive. It is generally recommended to limit naps to 20-30 minutes and to avoid napping late in the afternoon.

Choice B reason:
The statement "You should relax by watching a television show in bed before going to sleep" is not recommended. Watching television or using other electronic devices before bed can negatively impact sleep quality. The blue light emitted from screens can suppress melatonin production, making it harder to fall asleep. It is better to engage in relaxing activities that do not involve screens, such as reading a book or listening to calming music.

Choice C reason:
The statement "You should avoid stressful activities prior to going to sleep" is the correct response. Engaging in stressful activities before bed can increase anxiety and make it difficult to fall asleep. It is important to establish a relaxing bedtime routine that includes activities such as deep breathing exercises, meditation, or gentle stretching to promote better sleep.

Choice D reason:
The statement "You should plan to exercise 2 hours before going to sleep" is partially correct but not ideal. While regular exercise can improve sleep quality, exercising too close to bedtime can have the opposite effect for some people. It is generally recommended to finish exercising at least 3-4 hours before bedtime to allow the body to wind down.

Choice A Reason:
Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. High levels of stimuli can exacerbate hallucinations and increase agitation or anxiety. A calm and quiet environment helps reduce sensory overload and allows the client to feel more secure. This intervention is essential in managing symptoms and preventing potential harm to the client or others.

Choice B Reason:
Avoiding eye contact when speaking with the client is not recommended. Making eye contact is an important part of therapeutic communication and helps establish trust and rapport. It shows the client that the nurse is engaged and attentive. While it is important to be mindful of the client's comfort level, completely avoiding eye contact can be counterproductive and may make the client feel ignored or misunderstood.

Choice C Reason:
Encouraging increased socialization during group therapy can be beneficial for clients with schizophrenia, but it is not the most immediate intervention for those experiencing command hallucinations. Group therapy may be overwhelming for clients in acute distress. Initially, it is more important to stabilize the client's condition and ensure their safety before encouraging social interactions.

Choice D Reason:
Providing reassurance and comfort through touch can be helpful in some situations, but it must be approached with caution. Clients experiencing command hallucinations may misinterpret physical touch, leading to increased anxiety or agitation. It is important to assess the client's comfort with touch and use other forms of reassurance, such as verbal support and presence.