A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
Encourage the client to lie down in a quiet room.
Refer to the hallucinations as if they are real.
Avoid eye contact with the client.
Ask the client directly what he is hearing.
The Correct Answer is D
A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. A laissez-faire leader avoids lecturing or providing structured guidance.
B. A laissez-faire leader typically does not impose rules of silence but allows the group to engage freely.
C. While group members may participate, decisions about what to learn are not typically voted on in this style.
D. The laissez-faire leadership style is characterized by allowing group members to discuss topics freely without much interference.
Correct Answer is D
Explanation
Incorrect. Obesity is not a contraindication for acupuncture.
B. Incorrect. Hypothyroidism is not a contraindication for acupuncture.
C. Incorrect. Hypertension is not a contraindication for acupuncture.
D. Correct. Herpes zoster (shingles) involves a reactivation of the varicella-zoster virus and can cause skin lesions. Acupuncture involves the insertion of needles through the skin, which could potentially worsen the condition or lead to the spread of the virus.
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