What intervention is a priority when the client is experiencing auditory hallucinations?

Determine what precipitates these hallucinations.

Distract the client when hallucinating.

Determine the content of the hallucinations.

Let the client know you do not hear the voices.

Answer and Explanation

The Correct Answer is C

A.   While understanding precipitating factors is important, it is not the immediate priority when the client is actively experiencing hallucinations.
B.   Distracting the client may not address the underlying cause of the hallucinations, which should be the priority.
C.   Determining the content of the hallucinations can provide important information for assessment and intervention.
D.   Dismissing the client's experience can be alienating and unhelpful.

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Correct Answer is A

Explanation

A) Correct. Encouraging participation in physical activities can help channel excess energy and agitation associated with manic episodes.

B) Incorrect. Group card games may not provide an outlet for the high energy level typically seen in a manic episode.

C) Incorrect. While Bingo is a social activity, it may not be sufficient to address the high energy and potential restlessness seen in a manic episode.

D) Incorrect. Creating a new interactive game may not be feasible or appropriate in the acute setting, and it may not effectively address the client's current needs.

A. "As depression lifts, physical energy becomes available to carry out suicide." B. "Suicide may be precipitated by a variety of internal and external events." C. "Suicidal clients have difficulty using social supports." D. "Suicide is an impulsive act that has no warning."

Correct Answer is A

Explanation

A. "As depression lifts, physical energy becomes available to carry out suicide." This statement highlights a critical consideration in the care of severely depressed clients. When a client's depression starts to improve due to antidepressant therapy, there may be a period where they have increased energy but have not yet gained full relief from their depressive thoughts. This can potentially increase the risk of carrying out suicidal thoughts or plans.

B. "Suicide may be precipitated by a variety of internal and external events." While this statement is true, it does not specifically address the importance of monitoring a client during antidepressant therapy.

C. "Suicidal clients have difficulty using social supports." This statement acknowledges a potential challenge for clients who are experiencing suicidal thoughts, but it does not directly relate to the need for close monitoring during antidepressant therapy.

D. "Suicide is an impulsive act that has no warning." This statement is not entirely accurate. While some suicides can be impulsive, many individuals give warning signs or exhibit changes in behavior before attempting suicide.

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What intervention is a priority when the client is experiencing auditory hallucinations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?

Correct Answer is A

Explanation

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed client during antidepressant therapy?

Correct Answer is A

Explanation

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

A newly admitted client diagnosed with paranoid schizophrenia is super vigilant and constantly scans the environment. The client states, "I saw doctors talking in the hall. They were plotting to kill me." Which of the following does the nurse correctly identify as this behavior?

The nurse is admitting a client with the diagnosis of schizophreniform disorder. What should the nurse expect to find?

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

What intervention is a priority when the client is experiencing auditory hallucinations?

The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?