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 C
Explanation
A. Incorrect. Ensuring the device inspection sticker is current is important but not the first action to take when there's a potential safety issue.
B. Incorrect. Reporting the defect is important, but immediate action to ensure client safety should come first.
C. Correct. The nurse's first priority should be ensuring client safety. Removing the device from the room prevents any potential harm from using the device with a frayed cord.
D. Incorrect. Initiating a requisition for a replacement is important, but immediate action to ensure safety is a higher priority.
Correct Answer is D
Explanation
A. Incorrect. Premature atrial complexes do not typically affect the P-R interval. They are characterized by an early P-wave followed by a QRS complex.
B. Incorrect. Complete heart block is characterized by a dissociation between the P-waves and QRS complexes, resulting in no relationship between atrial and ventricular activity.
C. Incorrect. Atrial fibrillation is characterized by chaotic and irregular atrial activity without distinct P-waves, making the P-R interval irrelevant.
D. Correct. In first-degree atrioventricular block, the P-R interval is prolonged beyond the normal range of 0.12-0.20 seconds. A constant P-R interval of 0.35 seconds indicates a first- degree atrioventricular block.
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