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 B
Explanation
A. Incorrect. Bulging fontanels are not typically associated with withdrawal from maternal methadone use. They might indicate increased intracranial pressure or other conditions.
B. Correct. Hypertonicity, or increased muscle tone, is a common sign of neonatal withdrawal from opioids such as methadone. It can manifest as increased resistance to passive movement.
C. Incorrect. Bradycardia is not a common withdrawal symptom from maternal methadone use. Neonates withdrawing from opioids might experience tachycardia, not bradycardia.
D. Incorrect. Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to withdrawal from methadone. It can be related to immature peripheral circulation.
Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]
Explanation
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.
Membranes intact.
No uterine contractions noted.
FHR baseline 138, with minimal variability. No further reports of burning with urination.
Laboratory Results: WBC 12,000/mm3 (within the normal range of 5,000 to 10,000/mm3). Platelet count 188,000/mm3 (within the normal range of 150,000 to 400,000/mm3).
Vital Signs: Temperature 37.1°C (98.7°F), Blood pressure 120/78 mm Hg.
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