A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

Encourage the client to lie down in a quiet room.

Refer to the hallucinations as if they are real.

Avoid eye contact with the client.

Ask the client directly what he is hearing.

Answer and Explanation

The Correct Answer is D

A.   Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B.   Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C.   Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D.   Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.

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Correct Answer is D

Explanation

A. The balloon port is used to inflate or deflate the catheter balloon and is not used for obtaining urine specimens.
B. Unclamping the collection port could contaminate the specimen with non-sterile urine from the tubing.
C. Disconnecting the catheter from the collection tubing could introduce contaminants into the catheter and tubing.
D. Correct. The retention port is a sterile access point on the catheter itself, and it can be used to obtain a sterile urine specimen without compromising the sterility of the collection system.

A. Administer a cathartic suppository 30 min prior to scheduled defecation times. B. Encourage a maximum fluid intake of 1,500 mL per day. C. Increase the amount of refined grains in the client's diet. D. Provide the client with a cold drink prior to defecation.

Correct Answer is A

Explanation

A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.

B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.

C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.

D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.

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A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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