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","C","G","H"]

Explanation

Being well-groomed can be an indicator of improved mental health, as it suggests the client is taking care of their personal hygiene and appearance, which can be neglected during severe anxiety episodes.

An increase in the amount of sleep and a decrease in the frequency of nightmares can be seen as an improvement in the client’s condition, as sleep disturbances are common in anxiety disorders.

Engagement in thought-stopping behavioral therapy and cognitive restructuring indicates that the client is actively participating in therapeutic activities designed to manage anxiety, which is a positive sign of improvement.

Consistent medication adherence, as reported by the client taking escitalopram 20 mg daily, is crucial for managing anxiety symptoms and indicates the client’s commitment to following the treatment plan.

The client’s weight remaining stable could be neutral, as it does not indicate a significant change. Verbalizing decreased appetite and gastrointestinal discomfort, feeling anxious about leaving the house, and stating that past bullying has led to anxiety are all signs that the client is still experiencing symptoms of anxiety. Therefore, these choices do not reflect an improvement in the client’s condition.

A. Catch up on lost sleep by napping during the daytime. B. Avoid reading in the evenings prior to bedtime. C. Dim the screen on your cellphone when using it in your bedroom. D. Try meditation before you go to bed at night.

Correct Answer is D

Explanation

Choice A reason: Napping during the daytime can interfere with nighttime sleep patterns and is generally not recommended for individuals with insomnia. It can create a cycle of fragmented sleep and may exacerbate difficulties in falling and staying asleep at night.

Choice B reason: While avoiding stimulating activities such as reading in the evening can be helpful for some individuals, it is not a universal recommendation. Reading can actually be a relaxing activity for many people and may help them wind down before bedtime.

Choice C reason: Dimming the screen on electronic devices can reduce exposure to blue light, which can interfere with the body's natural sleep-wake cycle. However, it is generally recommended to avoid the use of electronic devices altogether in the bedroom to promote better sleep hygiene.

Choice D reason: Meditation is a relaxation technique that can be beneficial for individuals with PTSD and sleep disturbances. It can help calm the mind, reduce stress, and prepare the body for sleep. Mindfulness meditation, in particular, has been shown to improve sleep quality and is a recommended practice for those experiencing insomnia.

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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

Correct Answer is ["A","C","G","H"]

Explanation

A nurse is caring for a client who is being treated for posttraumatic stress disorder (PTSD). The client states, "I'm not able to fall asleep easily or stay asleep." Which of the following recommendations should the nurse make?

Correct Answer is D

Explanation

A nurse is preparing to administer 7 mg of haloperidol IM to a client who is severely agitated. Haloperidol injection of 5 mg/mL is available. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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