A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

Provide reassurance and comfort for the client through touch.

Encourage increased socialization during group therapy.

Avoid making eye contact when speaking with the client.

Maintain a low level of environmental stimuli.

Answer and Explanation

The Correct Answer is D

Choice A reason: Providing reassurance and comfort through touch can be beneficial in some cases; however, for clients experiencing command hallucinations, physical touch may be misinterpreted and could potentially escalate the situation. It's essential to gauge the client's comfort level with touch and proceed cautiously.

Choice B reason: While socialization is an important aspect of recovery, for a client experiencing command hallucinations, group therapy might be overwhelming and could exacerbate the hallucinations. It's crucial to introduce socialization gradually and in a controlled environment.

Choice C reason: Eye contact can be perceived as threatening or confrontational by clients with schizophrenia, especially when experiencing command hallucinations. It's important to respect the client's space and use non-confrontational body language to communicate effectively.

Choice D reason: Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. A calm and quiet environment can help reduce the intensity and frequency of hallucinations, providing a sense of safety and reducing stress and anxiety.

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Correct Answer is A

Explanation

Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.

Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.

Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.

Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.

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 creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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