A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

Sit in the chair next to the client.

Listen to what the client is saying.

Escort the client to his room.

Administer a PRN sedative.

Answer and Explanation

The Correct Answer is B

A.   Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B.   Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D.   Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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Correct Answer is B

Explanation

A. Showing the client the unit may be overwhelming and not address the immediate need for communication and building rapport.
B. Explaining the nurse's role helps establish trust and provides the client with information about who is present and their purpose.
C. Reading the client his/her rights is important but may be premature and not as immediately relevant as establishing communication.
D. Offering medication should come after establishing communication and assessing the client's needs, as not all clients may require or be ready for medication.

A. Participates in individual and group therapy. B. Demonstrates effective ways to cope with anxiety. C. Takes all antianxiety medications as prescribed. D. Learns methods of relaxation to reduce anxiety.

Correct Answer is B

Explanation

A. Participating in individual and group therapy is important for overall mental health, but the immediate focus is on addressing the self-harming behavior.
B. Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
C. Taking all antianxiety medications as prescribed is important but may not directly address the client's self-harming behavior.
D. Learning methods of relaxation is valuable, but the most immediate concern is preventing self-harm. The client should demonstrate effective ways to cope with anxiety to reduce the risk of self-injury.

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A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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