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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Listening carefully to the voices to hear what they're saying is not a recommended strategy for managing schizophrenia. Engaging with hallucinations can reinforce them and increase distress. Instead, clients are often taught to use distraction techniques or reality-testing strategies to manage auditory hallucinations. It is important for clients to recognize that the voices are a symptom of their condition and not something to be engaged with.
Choice B Reason:
Letting the counselor know if the client is having trouble sleeping is an important aspect of relapse prevention. Sleep disturbances can be an early warning sign of a potential relapse in schizophrenia. By informing their counselor, the client can receive timely interventions to address sleep issues and prevent a full-blown relapse. This proactive approach helps in managing symptoms and maintaining stability.
Choice C Reason:
Avoiding being around others if the client thinks they are having a relapse is not advisable. Social isolation can exacerbate symptoms and increase the risk of relapse. It is important for clients to stay connected with their support network and seek help if they notice signs of relapse. Engaging with others can provide emotional support and help in managing symptoms more effectively.
Choice D Reason:
Avoiding watching television when hearing voices is not a comprehensive strategy for managing hallucinations. While reducing exposure to certain stimuli can be helpful, it is more important for clients to use coping strategies and seek support from their healthcare team. Effective management of hallucinations involves a combination of medication, therapy, and support from mental health professionals.
Correct Answer is C
Explanation
Choice A reason:
The statement "Promote decision making about care" is not appropriate for a client experiencing delirium. Delirium can cause confusion, disorientation, and impaired decision-making abilities. Encouraging the client to make decisions about their care may increase their anxiety and confusion.
Choice B reason:
The statement "Discourage visits from significant others" is not advisable. Visits from familiar people can provide comfort and reassurance to a client experiencing delirium. Isolation can exacerbate feelings of confusion and distress.
Choice C reason:
The statement "Provide environmental cues" is the correct response. Environmental cues, such as clocks, calendars, and familiar objects, can help orient the client and reduce confusion. Maintaining a consistent routine and minimizing environmental changes can also promote safety and comfort.
Choice D reason:
The statement "Apply physical restraints" is not recommended as a first-line intervention. Physical restraints can increase agitation and the risk of injury. They should only be used as a last resort when the client poses an immediate danger to themselves or others and when less restrictive measures have failed.
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