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 B

Explanation

The correct answer is Choice B.

Choice A rationale: Worrying about a pimple, while significant for self-esteem, does not indicate an immediate risk. Addressing more serious concerns first is crucial, although self-esteem issues should be considered subsequently.

Choice B rationale: Expressing feelings of social isolation and dislike towards peers can indicate underlying mental health concerns, such as depression or anxiety. Addressing these feelings is a priority to provide support and prevent potential escalation.

Choice C rationale: Feeling that parents treat them like a baby can be part of normal adolescent development and is not typically a priority concern unless it significantly impacts the child's well-being.

Choice D rationale: Concerns about not having started menstruation are common and usually not immediately alarming unless accompanied by other signs of developmental delay. Reassurance and providing information can address this issue effectively.

A. Sweating. B. Decreased appetite. C. Discolored urine. D. Hallucinations.

Correct Answer is D

Explanation

Choice A rationale:

Sweating is not an adverse effect commonly associated with buspirone (Buspar). While some side effects like dizziness, nausea, and headache might occur, sweating is not typically reported as a significant adverse effect of this medication.

Choice B rationale:

Decreased appetite is a potential adverse effect of buspirone (Buspar). However, it is not the most concerning in this context. Anxiety disorders like generalized anxiety disorder can lead to appetite changes, and while this should be monitored, it is not a priority compared to more severe adverse effects.

Choice C rationale:

Discolored urine is not a common adverse effect of buspirone (Buspar). Buspirone is primarily used to treat anxiety and does not usually cause changes in urine color. This effect is unrelated to the medication and likely has a different underlying cause.

Choice D rationale:

Hallucinations are a concerning adverse effect that should be reported to the provider. Hallucinations are not a typical side effect of buspirone and might indicate a more serious issue or an interaction with other medications. Reporting this symptom promptly is crucial to ensuring the client's safety and well-being.

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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

Naxlex Comprehensive Predictor Exams

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

Correct Answer is B

Explanation

A nurse is taking care of a client who has generalized anxiety disorder and is taking buspar (Buspirone). Which of the following adverse effects should the nurse report to the provider?

Correct Answer is D

Explanation

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