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 B

Explanation

A. Incorrect. Encouraging the client to watch television might not provide the calming presence and support needed during a panic attack.

B. Correct. Sitting with the client and providing a sense of security can help them feel more grounded and supported during the panic attack.

C. Incorrect. Atomoxetine is not typically used to treat acute panic attacks. It's a medication used for attention deficit hyperactivity disorder (ADHD).

D. Incorrect. Teaching the client how to meditate might be beneficial in the long term, but during an acute panic attack, the client may not be receptive to learning new techniques.

A. The client is unable to obey commands. B. The client is oriented times three. C. The client opens eyes to sound. D. The client withdraws from pain.

Correct Answer is B

Explanation

A. Incorrect. A Glasgow coma scale (GCS) rating of 15 indicates that the client is able to obey commands.
B. Correct. A GCS rating of 15 indicates that the client is fully conscious and oriented to person, place, and time.
C. Incorrect. Opening eyes to sound is a response associated with the eye-opening component of the GCS score, but this response does not provide information about the client's orientation.
D. Incorrect. Withdrawing from pain is a response associated with the motor component of the GCS score, but this response does not provide information about the client's orientation.

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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?

Nursing Test Bank

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