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 B

Explanation

Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.

A. Lack of empathy B. Preoccupation with details C. Exploitative behavior D. Excessive clinging

Correct Answer is B

Explanation

Choice A reason: Lack of empathy is not a characteristic finding in OCPD. While individuals with OCPD may appear insensitive or less responsive to the needs and feelings of others due to their focus on rules and productivity, this does not equate to a true lack of empathy.

Choice B reason: Preoccupation with details is a hallmark of OCPD. Individuals with this disorder have an excessive concern with orderliness, perfectionism, and control over their environment and tasks. They may become so involved in making every detail perfect that it can hinder task completion and efficiency.

Choice C reason: Exploitative behavior is more characteristic of other personality disorders, such as narcissistic personality disorder, and is not a typical feature of OCPD. People with OCPD are more likely to be overly conscientious and fair in their dealings with others.

Choice D reason: Excessive clinging is not typically associated with OCPD. Instead, individuals with OCPD may have difficulty delegating tasks or working with others unless things are done precisely their way, which stems from their need for control rather than a need for closeness or reassurance.

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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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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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