A nurse is developing a plan of care for a client who is experiencing auditory hallucinations. Which of the following interventions should the nurse include in the plan?
Avoid making eye contact when speaking to the client.
Encourage the client to rest quietly in their room until the voices subside.
Determine if the client is experiencing command hallucinations.
Gently touch the client on the arm when speaking.
The Correct Answer is C
A. Avoid making eye contact when speaking to the client: Maintaining appropriate eye contact is important for building trust and therapeutic rapport. Avoiding eye contact may make the client feel ignored or increase anxiety, which can worsen hallucinations. Eye contact should be balanced and nonthreatening.
B. Encourage the client to rest quietly in their room until the voices subside: Isolating the client may exacerbate hallucinations or increase feelings of fear and paranoia. Active assessment and engagement are more effective than passive waiting for symptoms to resolve. The nurse should monitor the client and provide interventions to ensure safety.
C. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is a priority because they can instruct the client to harm themselves or others. Early identification allows the nurse to implement safety measures, provide appropriate interventions, and involve the healthcare team to reduce risk.
D. Gently touch the client on the arm when speaking: Physical touch can be misinterpreted by clients experiencing hallucinations or psychosis and may increase agitation or mistrust. Touch should only be used with caution and with explicit consent, and other noninvasive communication strategies are preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer a prescribed diuretic: Diuretics are used to promote urine production but are not the first-line intervention for postpartum urinary retention. They can cause fluid and electrolyte imbalances and do not address the underlying issue of bladder atony or difficulty initiating urination.
B. Apply an ice pack to the client's perineum: Ice packs are used to reduce perineal swelling and provide comfort after vaginal delivery, but they do not facilitate bladder emptying. Applying ice may actually inhibit urination by causing local vasoconstriction and decreased sensation.
C. Place the client's hands in warm water: Submerging the client’s hands in warm water can stimulate the micturition reflex via the parasympathetic nervous system. This noninvasive measure promotes relaxation of the urethral sphincter and facilitates spontaneous voiding, making it an appropriate first intervention for postpartum urinary retention.
D. Insert an indwelling catheter: Catheterization is effective for relieving acute urinary retention but is invasive and carries a risk of infection. It is reserved for cases when noninvasive measures, such as bladder scanning, positioning, or warm water stimulation, have failed.
Correct Answer is B
Explanation
A. Amino acid: Amino acids are the protein component of total parenteral nutrition (TPN). They provide essential and nonessential amino acids necessary for tissue repair, nitrogen balance, and protein synthesis. Amino acids are water-soluble and do not form emulsions, so they do not function as the fat component in TPN.
B. Egg phospholipid: Egg phospholipids serve as an emulsifying agent in intravenous fat emulsions. In TPN, the fat emulsion contains triglycerides suspended in water, and the phospholipid stabilizes the mixture, preventing separation. This allows safe delivery of essential fatty acids and caloric energy intravenously, making egg phospholipid a key component of the fat emulsion.
C. Folic acid: Folic acid is a water-soluble B vitamin included in TPN to prevent megaloblastic anemia and support DNA synthesis. It is not part of the lipid or fat component and does not function as an emulsifier.
D. Calcium gluconate: Calcium gluconate is an electrolyte added to TPN to maintain calcium balance. While important for metabolic and cardiac function, it is not a fat emulsion and does not provide caloric energy or act as an emulsifying agent.
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