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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Temporarily discontinuing the TPN infusion may result in an abrupt decrease in the client's glucose intake, which could lead to hypoglycemia.
B. Incorrect. Giving lactated Ringer's solution would not address the client's TPN needs and may also affect electrolyte balance.
C. Administering dextrose 10% in water wouldprovide the required glucosed as the next bag is awaited
D. Slowing the TPN infusion rate can help stretch the remaining volume until a new bag becomes available. However, it does not adress the body's glucose requirements.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Rationale:
• Obtain daily weights: Daily weights are used to monitor fluid balance in conditions like preeclampsia or heart failure. In this acute preterm labor scenario, the priority is monitoring fetal well-being and uterine activity, not long-term fluid shifts.
• Administer terbutaline: Terbutaline is a tocolytic medication used to suppress preterm labor by relaxing uterine smooth muscle. Given the client’s regular, strong contractions at 33 weeks with cervical changes, terbutaline may be prescribed to delay labor and allow fetal maturation.
• Administer oxytocin: Oxytocin stimulates uterine contractions and is used to induce or augment labor. In a client experiencing preterm labor at 33 weeks, oxytocin is contraindicated because it could worsen labor progression and increase risk of preterm birth.
• Administer betamethasone: Betamethasone is a corticosteroid administered to accelerate fetal lung maturity when preterm birth is imminent. Since the client is 33 weeks gestation and showing signs of preterm labor, administration is anticipated to reduce neonatal respiratory complications.
• Maintain modified bed rest with bathroom privileges: Modified bed rest can help reduce uterine stimulation, conserve energy, and support uteroplacental perfusion in clients experiencing preterm labor. Limiting physical activity is a standard intervention for preterm labor management.
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