A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?
Provide reassurance and comfort for the client through touch.
Encourage increased socialization during group therapy.
Avoid making eye contact when speaking with the client.
Maintain a low level of environmental stimuli.
The Correct Answer is D
Choice A reason: Providing reassurance and comfort through touch can be beneficial in some cases; however, for clients experiencing command hallucinations, physical touch may be misinterpreted and could potentially escalate the situation. It's essential to gauge the client's comfort level with touch and proceed cautiously.
Choice B reason: While socialization is an important aspect of recovery, for a client experiencing command hallucinations, group therapy might be overwhelming and could exacerbate the hallucinations. It's crucial to introduce socialization gradually and in a controlled environment.
Choice C reason: Eye contact can be perceived as threatening or confrontational by clients with schizophrenia, especially when experiencing command hallucinations. It's important to respect the client's space and use non-confrontational body language to communicate effectively.
Choice D reason: Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. A calm and quiet environment can help reduce the intensity and frequency of hallucinations, providing a sense of safety and reducing stress and anxiety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.
Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.
Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.
Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.
Correct Answer is A
Explanation
Choice A reason: Guided imagery is a relaxation technique that can help calm the mind and is beneficial for individuals with anxiety disorders. It involves envisioning a peaceful scene or series of experiences that can distract from anxious thoughts. This method can be particularly helpful before bedtime to ease the transition into sleep.
Choice B reason: Lying in bed and trying to force oneself to fall asleep can actually lead to increased frustration and anxiety, making it harder to fall asleep. It's recommended to leave the bed if unable to sleep and engage in a quiet activity until feeling sleepy.
Choice C reason: Eating a substantial meal before bed can lead to discomfort and disrupt sleep. It's better to have a light snack if needed and avoid heavy meals close to bedtime.
Choice D reason: Restricting sleep can exacerbate anxiety and is not recommended. It's important to maintain a regular sleep schedule and ensure adequate sleep to manage anxiety symptoms effectively.
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