A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions should the nurse take?
Administer a dose of fluoxetine to the client.
Avoid making eye contact with the client.
Request the client to lie down in a quiet room.
Encourage the client to listen to music.
The Correct Answer is D
A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.
B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.
C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.
D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Remove the skin markings following radiation: Skin markings should not be removed during radiation therapy, as they are necessary for accurate targeting of radiation. Removing them can interfere with treatment accuracy and is not recommended.
B. Apply lotions liberally to the skin: While moisturizing can help with dryness, during radiation therapy, the nurse should recommend only mild, non-irritating, fragrance-free lotions approved by the radiation team. Applying products liberally or unapproved lotions can interfere with radiation dosing.
C. Wear protective clothing when outside: Radiation can make the skin more sensitive to sunlight. Wearing protective clothing and using sun protection helps prevent additional irritation, burns, or damage to already vulnerable skin. This is an appropriate measure to manage skin integrity.
D. Cleanse skin with an antibacterial cleanser: Antibacterial or harsh cleansers can irritate the sensitive skin of a child undergoing radiation therapy. Gentle, mild, fragrance-free soap and lukewarm water are preferred to maintain skin integrity without causing further damage.
Correct Answer is A
Explanation
A. Implement firm but flexible boundaries in their relationship: Establishing boundaries helps both the client and adult child adapt to new caregiving roles while maintaining mutual respect and autonomy. Flexibility allows for adjustments as the client’s needs change, reducing role strain and promoting a healthy family dynamic.
B. Encourage authoritative communication from the adult child: While clear communication is important, an authoritative style may be perceived as controlling and can create tension. Collaborative, respectful communication is more effective in supporting role adjustment and maintaining family harmony.
C. Decrease socialization with extended relatives until roles are identified: Limiting social interactions is unnecessary and may increase isolation or stress. Maintaining connections with extended family can provide emotional support and resources during the transition.
D. Minimize open discussion regarding the changes to avoid embarrassment: Avoiding discussion about changes can lead to misunderstandings, unmet needs, and emotional strain. Open, honest communication helps clarify expectations, reduce conflict, and facilitate adjustment to new roles.
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