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. Hypertension is not typically associated with amniocentesis unless there are underlying conditions.
B. Epigastric pain may be a sign of other issues such as preeclampsia, but it is not a common complication following amniocentesis.
C. Correct. Amniocentesis can sometimes trigger contractions, especially if performed earlier in pregnancy. Monitoring for contractions is important to assess for preterm labor.
D. Vomiting is not a common complication of amniocentesis.

A. Perform a sterile dressing change for a client who has an abdominal wound. B. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus. C. Perform an admission assessment for a client who is scheduled for surgery. D. Complete the Glasgow Coma Scale for a client who has an evolving stroke.

Correct Answer is A

Explanation

A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).

B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.

C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.

D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.

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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

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