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","D","F"]

Explanation

A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.

B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.

C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.

D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.

E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.

F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.

A. The client displays agitation. B. The client becomes suddenly cheerful. C. The client experiences psychomotor retardation. D. The client does not attend group therapy.

Correct Answer is B

Explanation

A. Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B. Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C. Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D. Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)

Correct Answer is ["A","D","F"]

Explanation

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with premenstrual dysphoric disorder. What is the primary manifestation of this disorder?

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. What information should be included in the teaching? (Select all that apply.)

A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?

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