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

The correct answer is choice A: Request a mental health consult.

Choice A rationale:

Requesting a mental health consult is the first priority in this situation. The client's significant weight loss, distorted body image, and belief that she is fat suggest potential body dysmorphic disorder, eating disorder, or other psychological concerns. It's crucial to address these underlying issues before focusing on other aspects of care.

Choice B rationale:

Providing a structured environment can be beneficial, but it might not address the root cause of the client's psychological distress and distorted body image.

Choice C rationale:

Assessing the client's nutritional status is important to understand the physical impact of the weight loss, but the urgent need here is to address the client's psychological well-being and distorted self-perception.

Choice D rationale:

Planning a therapeutic diet for the client is essential, but it should not be the first priority. The client's belief that she is fat and her significant weight loss indicate deeper psychological issues that require immediate attention. Without addressing these psychological concerns, focusing solely on a diet plan might exacerbate her distorted body image and eating behaviors.

A. Aggressive behavior. B. Attention-seeking conduct. C. Mild fidgeting. D. Mild difficulty problem-solving.

Correct Answer is A

Explanation

Choice A rationale:

(Correct) Severe anxiety can lead to a fight-or-flight response, which might manifest as aggressive behavior. The individual might feel threatened and react defensively, potentially displaying aggressive actions to protect themselves.

Choice B rationale:

Attention-seeking conduct is less likely to be a primary manifestation of severe anxiety. While individuals with anxiety might seek reassurance or attention, the level of anxiety described here is more likely to evoke a defensive response rather than attention-seeking behavior.

Choice C rationale:

Mild fidgeting can be a manifestation of anxiety, but in the context of severe anxiety, the physical symptoms are often more pronounced, including restlessness, trembling, and muscle tension.

Choice D rationale:

Mild difficulty problem-solving is less likely to be a prominent manifestation of severe anxiety. Severe anxiety tends to affect the individual's ability to function and cope, leading to more intense and immediate reactions.

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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 nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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