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?

Maintain a low level of environmental stimuli.

Avoid making eye contact when speaking with the client.

Encourage increased socialization during group therapy.

Provide reassurance and comfort for the client through touch.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. High levels of stimuli can exacerbate hallucinations and increase agitation or anxiety. A calm and quiet environment helps reduce sensory overload and allows the client to feel more secure. This intervention is essential in managing symptoms and preventing potential harm to the client or others.

Choice B Reason:
Avoiding eye contact when speaking with the client is not recommended. Making eye contact is an important part of therapeutic communication and helps establish trust and rapport. It shows the client that the nurse is engaged and attentive. While it is important to be mindful of the client's comfort level, completely avoiding eye contact can be counterproductive and may make the client feel ignored or misunderstood.

Choice C Reason:
Encouraging increased socialization during group therapy can be beneficial for clients with schizophrenia, but it is not the most immediate intervention for those experiencing command hallucinations. Group therapy may be overwhelming for clients in acute distress. Initially, it is more important to stabilize the client's condition and ensure their safety before encouraging social interactions.

Choice D Reason:
Providing reassurance and comfort through touch can be helpful in some situations, but it must be approached with caution. Clients experiencing command hallucinations may misinterpret physical touch, leading to increased anxiety or agitation. It is important to assess the client's comfort with touch and use other forms of reassurance, such as verbal support and presence.

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Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

The client’s return for a follow-up examination after new onset of symptoms indicates a change in their health status that requires immediate attention.

Loss of appetite can be a sign of various health issues, including depression and other mental health disorders1. It’s important to address this symptom promptly to ensure the client is receiving proper nutrition.

Excessive sleepiness can be a symptom of several conditions, including depression, sleep disorders, and certain medical conditions1. It’s important to investigate this symptom further to determine its cause.

Becoming teary when asked about plans for activities could indicate emotional distress or depression. Mental health is a critical aspect of overall health, and this symptom should be addressed promptly.

Questioning the reason to live if not working is a serious symptom that could indicate suicidal ideation

This requires immediate attention and intervention.

While a dry, nonproductive cough can be a symptom of a respiratory condition, since breath sounds are present bilaterally, it may not require immediate attention. However, any persistent cough should be evaluated.

Occasional muscle aches and pains can be a symptom of various conditions, including fibromyalgia, influenza, and other infections1. It’s important to investigate this symptom further to determine its cause.

Reporting no energy could be a symptom of conditions such as depression, chronic fatigue syndrome, or anemia. This symptom should be addressed promptly to determine its cause and appropriate treatment.

A. Speak to the client in a loud voice. B. Identify the client's stressors. C. Stand directly in front of the client. D. Talk to the client using short, simple sentences. E. Request that security guards restrain the client.

Correct Answer is ["B","D"]

Explanation

Choice A reason:
The statement "Speak to the client in a loud voice" is not appropriate. Speaking loudly can escalate the client's agitation and increase their distress. It is important to use a calm, gentle tone to help de-escalate the situation.

Choice B reason:
The statement "Identify the client's stressors" is the correct response. Understanding what is causing the client's agitation can help in addressing the root cause and calming the client. Identifying stressors is a key step in managing agitation effectively.

Choice C reason:
The statement "Stand directly in front of the client" is not advisable. Standing directly in front of an agitated client can be perceived as confrontational and may increase their agitation. It is better to stand at an angle or to the side to avoid appearing threatening.

Choice D reason:
The statement "Talk to the client using short, simple sentences" is the correct response. Using clear, concise language helps the client understand instructions and reduces confusion, which can help in calming them down.

Choice E reason:
The statement "Request that security guards restrain the client" is not appropriate as a first response. Restraints should only be used as a last resort when the client poses an immediate danger to themselves or others and when less restrictive measures have failed.

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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","B","C","D","E","F","G"]

Explanation

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["B","D"]

Explanation

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