A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?
Ask the client direct questions about the hallucinations.
Act as if the hallucinations are real.
Instruct the client to argue with the voices.
Explain to the client that the hallucinations will subside soon.
The Correct Answer is A
Choice A Reason:
Ask the client direct questions about the hallucinations.
This response is the most appropriate because it allows the nurse to assess the content and nature of the hallucinations directly. By understanding what the client is experiencing, the nurse can better evaluate the risk of harm to the client or others and develop an appropriate care plan. Direct questioning helps in identifying whether the hallucinations are commanding the client to perform harmful actions, which is crucial for ensuring safety. This approach aligns with therapeutic communication techniques that emphasize understanding the client’s experience and providing appropriate interventions.
Choice B Reason:
Act as if the hallucinations are real.
This response is not appropriate because it can reinforce the client’s delusions and hallucinations, making it harder for them to distinguish between reality and their hallucinations. It is important for the nurse to maintain a reality-based approach while being empathetic and supportive. Acknowledging the client’s feelings without validating the hallucinations helps in maintaining a therapeutic environment.
Choice C Reason:
Instruct the client to argue with the voices.
Instructing the client to argue with the voices is not recommended as it can increase the client’s distress and confusion. Instead, the nurse should help the client develop coping strategies to manage the hallucinations, such as distraction techniques or reality testing. Encouraging the client to engage in a confrontation with their hallucinations can exacerbate their symptoms and is not a therapeutic approach.
Choice D Reason:
Explain to the client that the hallucinations will subside soon.
This response is not appropriate because it provides false reassurance. Hallucinations may not subside quickly, and the client needs realistic support and coping strategies to manage their symptoms. Providing false hope can undermine the client’s trust in the nurse and the treatment process. Instead, the nurse should focus on helping the client manage their symptoms effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
To calculate the infusion rate in drops per minute:
- Identify the total volume to be infused: 125 mL
- Identify the total time for infusion: 1 hour (which is 60 minutes)
- Identify the drop factor: 60 gtts/mL
Step 1: Calculate the infusion rate in mL per minute.
- Volume (mL) ÷ Time (minutes)
- 125 mL ÷ 60 minutes = 2.0833 mL per minute
Step 2: Calculate the infusion rate in drops per minute.
- Infusion rate (mL per minute) × Drop factor (gtts/mL)
- 2.0833 mL per minute × 60 gtts/mL = 125 gtts per minute
The drug will infuse at 125 drops per minute.
Correct Answer is D
Explanation
Choice A Reason:
The statement “The client is always aware that their behaviors are maladaptive” is incorrect. While individuals with neurotic behavior may sometimes recognize that their behaviors are maladaptive, this awareness is not consistent. Neurotic behaviors are often automatic and unconscious efforts to manage deep anxiety. Therefore, the client may not always be aware of the maladaptive nature of their actions.
Choice B Reason:
The statement “The client uses adaptive defense mechanisms to cope” is incorrect. Neurotic behavior typically involves the use of maladaptive defense mechanisms rather than adaptive ones. These mechanisms, such as denial, repression, or projection, are employed to manage anxiety and stress but do not effectively resolve the underlying issues. Adaptive defense mechanisms, on the other hand, are more constructive and promote healthier coping strategies.
Choice C Reason:
The statement “The client never has mood or personality changes” is incorrect. Neurotic behavior is often associated with mood swings and emotional instability. Clients with neurotic tendencies may experience frequent changes in mood and may struggle with regulating their emotions. Therefore, it is inaccurate to state that the client never has mood or personality changes.
Choice D Reason:
The statement “The client does not experience loss of contact with reality” is correct. Neurotic behavior, unlike psychotic behavior, does not involve a loss of contact with reality4. Clients with neurotic tendencies remain aware of their surroundings and can distinguish between reality and their internal experiences4. This characteristic differentiates neurotic behavior from more severe mental health conditions such as schizophrenia, where a loss of reality is a key feature.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today