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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Holding the client's eyes shut for a few seconds after death helps keep the eyelids closed and gives a more peaceful appearance.
B. Incorrect. Crossing the client's arms across their chest is not typically part of postmortem care and may not be culturally appropriate in some cases.
C. Incorrect. Removing dentures from the mouth is not a standard step in postmortem care unless specifically requested by the family or if they pose a risk of aspiration.
D. Incorrect. Placing the client in a high-Fowler's position is not necessary after death and is not part of postmortem care.
Correct Answer is C
Explanation
A. Prednisone should generally be taken with food or after a meal to reduce the risk of gastric irritation or ulcer formation. Taking it on an empty stomach can irritate the stomach lining and increase the risk of gastrointestinal side effects, such as gastritis or peptic ulcers.
B. While some medications are best taken at bedtime (such as those with sedative effects), prednisone is a corticosteroid that can affect the body's circadian rhythm and may interfere with sleep. It typically causes insomnia or restlessness, so it’s usually advised to take it in the morning.
C. Prednisone and other corticosteroids can lead to bone loss (osteoporosis) over time, especially with long-term use. One of the side effects of corticosteroid therapy is decreased calcium absorption and bone density loss, making individuals at higher risk for fractures.
D. Prednisone more commonly causes weight gain rather than weight loss. Corticosteroids increase appetite and can lead to fluid retention, both of which can result in weight gain. Additionally, prednisone can cause redistribution of fat, often leading to characteristic side effects like "moon face" or increased abdominal fat.
B. Incorrect. Prednisone is often prescribed as a single daily dose in the morning to coincide with the body's natural cortisol release.
C. Incorrect. While calcium supplementation might be necessary for some individuals on long-term prednisone therapy, it is not a primary instruction related to taking prednisone.
D. Correct. Monitoring for weight loss is important due to the potential for weight changes (both weight gain and weight loss) as a result of prednisone's effects on metabolism and appetite.
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