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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: "Tell me more about your concerns about taking chemotherapy."
Choice A rationale:
This response focuses on negative outcomes and might discourage the client from exploring her options. It does not support the client's autonomy or address her concerns about nontraditional treatments. The nurse's role should be to facilitate open communication and understanding.
Choice B rationale:
This response is the most therapeutic. By inviting the client to share her concerns, the nurse demonstrates empathy and encourages the client to express her thoughts and feelings. This approach fosters a collaborative and respectful relationship, allowing the nurse to address the client's worries effectively.
Choice C rationale:
This response is directive and dismissive of the client's wishes. It fails to consider the client's perspective and autonomy. The nurse should avoid imposing personal opinions and instead promote a patient-centered approach.
Choice D rationale:
While acknowledging the provider's expertise is important, this response does not address the client's concerns about nontraditional treatments. It's essential to focus on the client's individual preferences and provide information to help her make an informed decision.
Correct Answer is B
Explanation
Choice A rationale:
Telling the parents that they should not feel guilty might invalidate their emotions and discourage open communication. It's essential to acknowledge their feelings and address them empathetically.
Choice B rationale:
This choice demonstrates therapeutic communication and empathy. It encourages the parents to express their feelings, and the nurse is offering to listen and explore the reasons behind their guilt.
Choice C rationale:
This statement seems confrontational and may discourage the parents from sharing their emotions openly. Asking why they feel guilty immediately might put them on the defensive.
Choice D rationale:
While this statement acknowledges the difficulty of the situation, it ends with a premature reassurance that may not be well-received. The parents need space to discuss their feelings before focusing on the future.
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