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?

Maintain a low level of environmental stimuli.

Avoid making eye contact when speaking with the client.

Encourage increased socialization during group therapy.

Provide reassurance and comfort for the client through touch.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. High levels of stimuli can exacerbate hallucinations and increase agitation or anxiety. A calm and quiet environment helps reduce sensory overload and allows the client to feel more secure. This intervention is essential in managing symptoms and preventing potential harm to the client or others.

Choice B Reason:
Avoiding eye contact when speaking with the client is not recommended. Making eye contact is an important part of therapeutic communication and helps establish trust and rapport. It shows the client that the nurse is engaged and attentive. While it is important to be mindful of the client's comfort level, completely avoiding eye contact can be counterproductive and may make the client feel ignored or misunderstood.

Choice C Reason:
Encouraging increased socialization during group therapy can be beneficial for clients with schizophrenia, but it is not the most immediate intervention for those experiencing command hallucinations. Group therapy may be overwhelming for clients in acute distress. Initially, it is more important to stabilize the client's condition and ensure their safety before encouraging social interactions.

Choice D Reason:
Providing reassurance and comfort through touch can be helpful in some situations, but it must be approached with caution. Clients experiencing command hallucinations may misinterpret physical touch, leading to increased anxiety or agitation. It is important to assess the client's comfort with touch and use other forms of reassurance, such as verbal support and presence.

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Correct Answer is C

Explanation

Choice A Reason:
Documenting the client's behavior every 60 minutes is important for monitoring the client's condition and ensuring their safety. However, it is not the most immediate action required following the initiation of seclusion. Continuous documentation helps in assessing the effectiveness of the intervention and making necessary adjustments to the care plan.

Choice B Reason:
Keeping the client in seclusion for no longer than 6 hours is a guideline to prevent prolonged isolation, which can have negative psychological effects. However, this is not the first action the nurse should take. The duration of seclusion should be based on the client's behavior and the clinical judgment of the healthcare team.

Choice C Reason:
Obtaining a prescription for seclusion within 30 minutes is crucial because it ensures that the use of seclusion is medically justified and legally documented. This action aligns with regulatory requirements and best practices in mental health care. It ensures that the intervention is necessary and that the client's rights are protected.

Choice D Reason:
Monitoring the client's vital signs every 4 hours is essential for assessing the client's physical health and detecting any adverse effects of seclusion. However, like documenting behavior, it is not the most immediate action required. Regular monitoring helps in ensuring the client's safety and well-being during the period of seclusion.

A. "Don't worry about it. Your anxiety will lessen once the massage begins." B. "I will request that the massage therapist wear gloves during your treatment." C. "Why don't you like to be touched by others?" D. "I will tell your provider that you would like a treatment other than massage."

Correct Answer is D

Explanation

Choice A reason:
The statement "Don't worry about it. Your anxiety will lessen once the massage begins" is not appropriate. This response dismisses the client's expressed discomfort and does not address their concerns. It is important to validate the client's feelings and work collaboratively to find an acceptable alternative.

Choice B reason:
The statement "I will request that the massage therapist wear gloves during your treatment" is not a suitable solution. Wearing gloves may not alleviate the client's discomfort with being touched and could still cause anxiety. It is better to explore other treatment options that do not involve physical contact.

Choice C reason:
The statement "Why don't you like to be touched by others?" is not the best approach. While understanding the client's reasons can be helpful, this question may come across as intrusive or judgmental. It is more important to respect the client's boundaries and preferences.

Choice D reason:
The statement "I will tell your provider that you would like a treatment other than massage" is the correct response. This response acknowledges the client's discomfort and takes appropriate action to find an alternative treatment that the client is comfortable with. It shows respect for the client's preferences and ensures their needs are met.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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