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 A

Explanation

Choice A reason: Autonomy is the principle that addresses the patient's right to make their own decisions regarding their health care, based on their own values and preferences. When the nurse supports the client's refusal of medications, they are respecting the client's autonomy. This principle is fundamental in healthcare ethics, emphasizing the belief that patients are capable of making informed decisions about their own treatment.

Choice B reason: Beneficence involves actions that promote the well-being of others. In the context of healthcare, this principle often refers to the healthcare provider's duty to act in the patient's best interest. While beneficence is important, it must be balanced with autonomy, especially when the patient's wishes are known and legally sound.

Choice C reason: Veracity refers to the obligation to tell the truth and not deceive others. In the healthcare setting, this means providing accurate information to patients about their condition and treatment options. While veracity is crucial, it does not directly relate to the support of a patient's decision to refuse treatment.

Choice D reason: Justice in healthcare is about fairness in the distribution of resources and respect for people's rights. It involves ensuring that all individuals have equal access to treatment and care. The principle of justice does not specifically address the issue of supporting a patient's decision to refuse treatment.

A. Instruct the client to expect ringing in the ears. B. Place the client in restraints for 1 hour. C. Initiate fall precautions for the client. D. Repeat the dose in 15 minutes if the client is still anxious.

Correct Answer is C

Explanation

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

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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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