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 A
Explanation
A. Correct. Epiglottitis can cause airway obstruction, so continuous respiratory monitoring is crucial to detect any signs of respiratory distress.
B. Incorrect. Administering pancreatic enzymes is not relevant to epiglottitis.
C. Incorrect. Frequent swallowing assessment is not the priority for epiglottitis. Airway management is.
D. Incorrect. Suctioning may be necessary, but continuous respiratory monitoring takes precedence.
Correct Answer is A
Explanation
A. Correct. Banana slices are a soft and easily manageable food that encourages a toddler's independence in eating. They can be easily held by the toddler and self-fed.
B. Incorrect. Hot dogs are a choking hazard due to their shape and texture, which can increase the risk of choking in young children.
C. Incorrect. Grapes are also a choking hazard for young children, as they can easily block the airway if not cut into small pieces.
D. Incorrect. Popcorn is a choking hazard due to its size, shape, and hardness. It should be avoided in young children.
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