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 {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
A. Hypoglycemia might be a concern if the baby had risk factors like maternal diabetes, but this information is not provided.
B. Tachycardia is not mentioned as a concern in the scenario, and the heart rate is within normal limits for a newborn
C. Bronchopulmonary Dysplasia (BPD): The newborn's respiratory rate is increasing over time, along with the presence of grunting and retractions. These are signs of respiratory distress. Bronchopulmonary dysplasia (BPD) is a chronic lung disease that primarily affects premature infants who require mechanical ventilation and oxygen therapy for an extended period. The symptoms align with the respiratory distress and could suggest a risk for BPD.
D. Transient Tachypnea of the Newborn (TTN): The newborn's respiratory rate is increasing over time, along with grunting and retractions. These signs are consistent with transient tachypnea of the newborn, which is a self-limiting condition characterized by rapid breathing shortly after birth. It is more common in infants born via cesarean delivery and may result from delayed clearance of lung fluid.
Correct Answer is B
Explanation
Choice A rationale:
Storing unused patches in the refrigerator is not necessary for transdermal scopolamine patches. Refrigeration is not a requirement for their storage.
Choice B rationale:
Applying the patch prior to traveling is the correct choice. Transdermal scopolamine patches are used to prevent motion sickness. Applying the patch before the journey allows the medication to be absorbed before exposure to motion, ensuring its effectiveness during travel.
Choice C rationale:
Placing the patch on the upper arm is a specific and correct instruction for applying transdermal scopolamine patches. The patch should be placed on a clean, dry, and hairless area of the skin, preferably behind the ear or on the upper arm.
Choice D rationale:
Replacing a dislodged patch onto the same location is incorrect. If the patch becomes dislodged, it should be replaced with a new patch on a different, clean, and dry area of the skin. Reapplying a dislodged patch to the same spot may result in uneven absorption and reduced effectiveness.
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