A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Ask the client direct questions about the hallucination.

Act to the client as if the hallucination is real.

Tell the client to go to their room and they should go away.

Instruct the client to argue with the voices that are a part of the hallucination.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Ask the client direct questions about the hallucination.

Choice A rationale:

Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.

Choice B rationale:

Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.

Choice C rationale:

Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.

Choice D rationale:

Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.

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Correct Answer is A

Explanation

Choice A rationale:

This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.

Choice B rationale:

Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.

Choice C rationale:

Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.

Choice D rationale:

Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.

A. Tachycardia. B. Tremors. C. Hallucinations. D. Hypotension. E. Seizures.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale:

Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.

Choice B rationale:

Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.

Choice C rationale:

Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.

Choice E rationale:

Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.

Choice D rationale:

Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.

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A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Nursing Test Bank

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