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
A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
- A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
- A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
- A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia
Correct Answer is D
Explanation
Choice A rationale:
Oxytocin is not typically administered during a nonstress test. Oxytocin is a hormone that induces or augments labor contractions; it is not used in nonstress testing, which monitors fetal heart rate and movement. The administration of oxytocin during nonstress testing would not be appropriate or necessary.
Choice B rationale:
Fasting is not required for a nonstress test. Nonstress testing involves attaching electronic fetal monitors to the mother's abdomen to measure the baby's heart rate and movement. It does not require the patient to abstain from eating or drinking. Imposing unnecessary restrictions on the client's diet could cause discomfort and anxiety, which is not conducive to an accurate assessment.
Choice C rationale:
Nonstress testing is used to evaluate the baby's heart rate response to its own movements. It does not diagnose genetic problems. Genetic testing, such as amniocentesis or chorionic villus sampling, is a different type of test used to detect genetic abnormalities in the fetus. Therefore, this statement does not reflect an understanding of the purpose of nonstress testing.
Choice D rationale:
This is the correct answer. Nonstress testing involves monitoring the baby's heart rate and movement. During the test, the mother pushes a button when she feels the baby move. This allows the healthcare provider to correlate fetal movements with changes in the baby's heart rate. An understanding of this process indicates that the client comprehends the purpose and procedure of the nonstress test.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.