A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

Tell the client that their experience is not real.

Avoid asking direct questions about the client's experience.

Focus the client on reality-based activities.

Convey sympathy for the client's experience.

Answer and Explanation

The Correct Answer is C

Choice A reason: Telling a client that their experience is not real can be invalidating and may damage the therapeutic relationship between the nurse and the client. It is essential to acknowledge the client's experience as real to them and provide support without reinforcing the hallucination.

Choice B reason: While it is important not to reinforce hallucinations, avoiding direct questions about the client's experience can hinder the nurse's ability to assess the client's condition fully. It is better to ask open-ended questions that allow the client to describe their experience without feeling judged.

Choice C reason: Focusing the client on reality-based activities can help distract them from the hallucinations and ground them in the present moment. Activities such as listening to music, engaging in conversation, or participating in a physical activity can help reduce the intensity of hallucinations and provide a sense of control.

Choice D reason: Conveying sympathy for the client's experience is compassionate and can help build trust. However, it is crucial to balance empathy with encouragement to engage in reality-based activities and strategies to manage the hallucinations effectively.

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Correct Answer is D

Explanation

Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.

Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.

Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.

Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.

A. "If you attend counseling, you will get your child back." B. "We can ask the physician to prescribe a sedative." C. "Have you thought about harming yourself?" D. "Can a family member try to obtain temporary custody of your child?"

Correct Answer is C

Explanation

Choice A reason: This response is not therapeutic as it provides false assurance and may not be accurate. The return of the child depends on many factors beyond just attending counseling.

Choice B reason: While sedatives may be used to manage acute distress, this response does not address the client's expressed feelings of hopelessness and the risk of self-harm.

Choice C reason: This response directly addresses the client's statement about not wanting to live, which could indicate suicidal ideation. It is important to assess for the risk of self-harm or suicide.

Choice D reason: This response may be helpful in a long-term plan but does not address the immediate risk of harm to the client. It is also not guaranteed that a family member can obtain custody.

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A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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