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: Constant talking is a common indicator of mania in individuals with bipolar disorder. During manic episodes, clients may experience pressured speech, which is fast, incessant, and difficult to interrupt. This symptom reflects the increased energy and reduced need for sleep that are characteristic of mania.

Choice B reason: While memory loss is not a definitive indicator of mania, it can occur in bipolar disorder. However, it is more commonly associated with either depressive episodes or the aftermath of a manic episode, rather than the manic phase itself.

Choice C reason: Excessive sleep is typically not associated with mania. In fact, a decreased need for sleep is one of the diagnostic criteria for a manic episode. Clients in a manic phase often feel rested after only a few hours of sleep.

Choice D reason: Expressing feelings of inferiority is not typically indicative of mania. Such feelings are more commonly associated with depressive episodes. Manic episodes often involve inflated self-esteem or grandiosity.

A. "Have you talked to your family about your diagnosis?" B. "These feelings are an expected part of anticipatory grieving." C. "I'm sure the nurses are trying to take good care of you." D. "Can you tell me more about what is upsetting you?"

Correct Answer is D

Explanation

Choice A reason: While discussing the client's diagnosis with their family could be part of the care process, it does not address the client's immediate concern about the quality of care they are receiving. This response does not validate the client's feelings or provide an opportunity for them to elaborate on their concerns.

Choice B reason: Telling the client that their feelings are part of anticipatory grieving may be true, but it can come across as dismissive and does not offer support for the specific issue the client has raised about the quality of care.

Choice C reason: Assuring the client that the nurses are trying to provide good care does not acknowledge the client's perception of inadequate care. It's important to validate the client's feelings and understand their perspective before offering reassurances.

Choice D reason: Asking the client to elaborate on their concerns shows empathy and a willingness to listen. It allows the nurse to gather more information about the client's experience and identify specific areas that may need improvement in the care provided.

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