A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?
Tell the client that there is nothing there.
Ask the client to describe what is being seen.
Touch the client's arm reassuringly.
Remove the client from the room.
The Correct Answer is B
A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a noninvasive treatment that helps individuals with depression by identifying and modifying negative thought patterns and behaviors. It is widely used and effective in improving mood, coping skills, and overall mental well-being.
B. Vagal nerve stimulation. Vagal nerve stimulation (VNS) is an invasive procedure that involves implanting a device to stimulate the vagus nerve. It is used for treatment-resistant depression and is not considered a first-line, noninvasive option.
C. Electroconvulsive therapy. Electroconvulsive therapy (ECT) is a medical procedure that involves electrical stimulation of the brain under anesthesia. Although effective for severe depression, it is invasive and typically reserved for cases that do not respond to medication or therapy.
D. Deep-brain stimulation. Deep-brain stimulation (DBS) involves surgically implanting electrodes in specific brain regions to regulate mood-related neural activity. It is an invasive treatment used in research or for severe, treatment-resistant depression.
Correct Answer is D
Explanation
A. Preparation: In this stage, individuals recognize the need for change and start making plans, such as gathering information or setting goals. The client, however, shows no intent to change dietary habits.
B. Action: This stage involves actively modifying behaviors and consistently implementing changes. The client is not taking any steps toward dietary adjustments, indicating they are not in this stage.
C. Contemplation: Individuals in this stage acknowledge the need for change and consider making adjustments but have not yet committed. The client, by dismissing the information, is not showing contemplation.
D. Precontemplation: This stage is characterized by a lack of awareness or denial of the need for change. The client’s response suggests they do not see dietary restrictions as necessary and are resistant to modifying their eating habits.
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