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 D

Explanation

Choice A reason:
The statement "I will notify law enforcement within 2 hours if he cannot be found" is not the best practice. In cases where a person with Alzheimer's disease goes missing, it is crucial to notify law enforcement immediately. Delaying notification can reduce the chances of finding the person quickly and safely.

Choice B reason:
The statement "I will give his most recent photo to the police" is a good practice but does not directly relate to home safety. Providing a recent photo to the police can be helpful if the person goes missing, but it is not a preventive measure to ensure safety at home.

Choice C reason:
The statement "I will ensure the bedroom is dark while he is sleeping at night" is not advisable. People with Alzheimer's disease may experience increased confusion and agitation in the dark. A dim nightlight can help reduce disorientation and provide a safer environment.

Choice D reason:
The statement "I will place a sliding bolt lock just above the doorknob" is the correct response. Installing locks that are difficult for the person with Alzheimer's to reach or operate can help prevent wandering, which is a common and dangerous behavior in individuals with advanced Alzheimer's disease.

A. Limit visitation from the client’s family. B. Reorient the client to person, place, and time frequently. C. Rotate nursing staff daily. D. Approach the client slowly. E. Maintain a low-stimulation environment.

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Limiting visitation from the client’s family may not be beneficial as the presence of familiar people can often help reorient and calm the client. Family members can provide comfort and reassurance, which can be particularly helpful for a client experiencing delirium.
Choice B reason: Reorienting the client to person, place, and time frequently is a recommended intervention for patients with delirium. This can help reduce confusion and agitation in clients with delirium.
Choice C reason: Rotating nursing staff daily could potentially increase confusion for the client, as continuity of care and familiar faces can be beneficial in managing delirium. Therefore, this option is not recommended.
Choice D reason: Approaching the client slowly is a recommended intervention for patients with delirium. Given the client’s agitation and confusion, it’s important to approach them in a non-threatening manner to avoid escalating their distress.
Choice E reason: Maintaining a low-stimulation environment is a recommended intervention for patients with delirium. A calm and quiet environment can help reduce agitation and confusion in clients with delirium.

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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

A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?

Correct Answer is D

Explanation

The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415. Exhibits Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Correct Answer is ["B","D","E"]

Explanation

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