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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Incorrect. Family history of malignant hypertension is not a contraindication for alteplase.

B. Incorrect. COPD itself is not a contraindication for alteplase. While it can complicate overall management, it does not increase the immediate risk of bleeding associated with thrombolytics.

C. Correct. Recent surgery, especially orthopedic surgery like hip arthroplasty, is a contraindication for thrombolytic therapy due to the increased risk of bleeding and hematoma formation at the surgical site.

D. Incorrect. Acute renal failure from six months ago is not a contraindication for alteplase.

A. Use soap and water to provide perineal care. B. Change the indwelling urinary catheter tubing every 3 days C. Encourage the client to drink 3000 ml of fluid daily. D. Review the need for the indwelling urinary catheter daily F. Place the drainage beg on the bed when transporting the client

Correct Answer is ["A","D","E"]

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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