A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?

“I know you hear the voices, but I do not.”

“How often do you hear the voices?”

“What are the voices telling you?”

“The voices are part of your illness.”

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.

Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.

Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.

Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.

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Correct Answer is D

Explanation

The correct answer is D. Limit the client’s participation in group activities.

Explanation:

Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.

Why the other options are incorrect:

A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.

A. “I will contact my provider if I have difficulty urinating.” B. “I might notice an increased frequency of my menstrual cycle.” C. “These medications might cause breast tissue to atrophy.” D. “I am at a decreased risk for infection while taking these medications.”

Correct Answer is A

Explanation

Choice A rationale:

I will contact my provider if I have difficulty urinating.

Chlorpromazine has anticholinergic effects, which can cause urinary retention. This means the medication can interfere with the normal function of the bladder, making it difficult to empty completely. Difficulty urinating can lead to bladder distention, urinary tract infections, and even kidney damage if left untreated.

It's crucial for the client to recognize this potential side effect and seek medical attention promptly if it occurs. Early intervention can help prevent complications and ensure proper bladder management.

By understanding this potential side effect and the importance of seeking help, the client demonstrates a grasp of the teaching provided.

Choice B rationale:

I might notice an increased frequency of my menstrual cycle.

Chlorpromazine does not typically affect menstrual frequency. While some antipsychotic medications can cause menstrual irregularities, chlorpromazine is not commonly associated with this effect.

If a client experiences changes in their menstrual cycle while taking chlorpromazine, it's important to discuss it with their healthcare provider to rule out other potential causes.

Choice C rationale:

These medications might cause breast tissue to atrophy.

Chlorpromazine is not known to cause breast atrophy. Breast atrophy, or shrinkage of breast tissue, can occur due to hormonal changes, aging, or certain medical conditions.

However, it's not a common side effect of chlorpromazine.

Choice D rationale:

I am at a decreased risk for infection while taking these medications.

Chlorpromazine does not decrease the risk of infection. In fact, it may slightly increase the risk of infection due to its potential to suppress the immune system.

It's essential for clients taking chlorpromazine to practice good hygiene and infection prevention measures to protect themselves from illness.

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A nurse is caring for a client who is experiencing auditory hallucinations. What should the nurse say first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior. Which of the following interventions should the nurse recommend to be included in the plan of care?

Correct Answer is D

Explanation

Explanation:

Why the other options are incorrect:

A nurse is reinforcing teaching with a female client who is prescribed chlorpromazine. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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A nurse is caring for a client who has schizophrenia and notices changes in the client’s behavior. Which of the following behaviors is the nurse’s priority to report to the provider?

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client demonstrates concrete thinking?

A nurse is conversing with a client diagnosed with schizophrenia. Suddenly, the client expresses fear, stating, “I’m scared. Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?

A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?