A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

Tell the client that their experience is not real.

Avoid asking direct questions about the client's experience.

Focus the client on reality-based activities.

Convey sympathy for the client's experience.

Answer and Explanation

The Correct Answer is C

Choice A reason: Telling a client that their experience is not real can be invalidating and may damage the therapeutic relationship between the nurse and the client. It is essential to acknowledge the client's experience as real to them and provide support without reinforcing the hallucination.

Choice B reason: While it is important not to reinforce hallucinations, avoiding direct questions about the client's experience can hinder the nurse's ability to assess the client's condition fully. It is better to ask open-ended questions that allow the client to describe their experience without feeling judged.

Choice C reason: Focusing the client on reality-based activities can help distract them from the hallucinations and ground them in the present moment. Activities such as listening to music, engaging in conversation, or participating in a physical activity can help reduce the intensity of hallucinations and provide a sense of control.

Choice D reason: Conveying sympathy for the client's experience is compassionate and can help build trust. However, it is crucial to balance empathy with encouragement to engage in reality-based activities and strategies to manage the hallucinations effectively.

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Correct Answer is A

Explanation

Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.

Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.

Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.

Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.

A. Ask the client what they are hearing. B. Focus the client on reality-based topics. C. Take the client for a walk outside. D. Encourage the client to listen to music.

Correct Answer is A

Explanation

Choice A reason: Asking the client about their hallucinations can provide valuable information about the content and nature of the hallucinations. This can help the nurse assess the client's current mental state and the potential impact of the hallucinations on their behavior and safety.

Choice B reason: Focusing the client on reality-based topics is a strategy that can be used after understanding the client's hallucinations. It's important to first acknowledge the client's experience before attempting to redirect their attention.

Choice C reason: Taking the client for a walk may be a good distraction technique, but it should not be the first action. The nurse needs to assess the client's safety and the potential risks associated with the hallucinations before engaging in activities.

Choice D reason: Encouraging the client to listen to music can be a therapeutic intervention to help distract from hallucinations. However, it is not the first action to take. The nurse should first understand the client's experience and ensure their safety.

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A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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