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

Choice A rationale:

Telling the newly diagnosed cancer clients that they need to work hard on resolving conflicts with those closest to them may come across as insensitive and dismissive of their emotional struggles. Cancer diagnosis often brings about complex emotions, and this response does not acknowledge or address their concerns.

Choice B rationale:

This response acknowledges the client's statement and encourages further discussion about their feelings regarding their inability to return to work. It shows empathy and a willingness to explore their concerns, promoting open communication and emotional support.

Choice C rationale:

Commenting on the client's physical behavior without context might make them uncomfortable or self-conscious. The nurse's observation about fist clenching should be addressed more delicately if relevant, and the focus should be on the emotional aspect rather than the physical behavior.

Choice D rationale:

Dismissing the potential benefit of antidepressants and promoting the therapy group might undermine the client's feelings and choices. While group therapy can be beneficial, this response overlooks the potential need for a multifaceted approach to treatment, which could include therapy and medication.

A. "There's a big pimple on my face, and I worry that everyone will notice it." B. "None of the kids at this school like me, and I don't like them either." C. "My parents treat me like a baby sometimes." D. "I haven't gotten my period yet, and all my friends have theirs.".

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.

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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 is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?

Correct Answer is B

Explanation

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

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