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 B

Explanation

Choice A rationale:

Varicella vaccine is typically administered to children at the age of 1 year, not at 2 months. The first dose of varicella vaccine is usually given at 12-15 months of age, with a second dose recommended at 4-6 years of age.

Choice B rationale:

Rotavirus vaccine is recommended to be administered to infants at the age of 2 months. It is an oral vaccine that protects against rotavirus infections, a common cause of severe diarrhea and dehydration in infants and young children.

Choice C rationale:

Influenza vaccine is not typically administered to infants at 2 months of age. Influenza vaccination is recommended annually for children older than 6 months.

Choice D rationale:

Hepatitis A vaccine is not routinely given at 2 months of age. Hepatitis A vaccination is typically recommended starting at 1 year of age, with a second dose administered 6-18 months later.

A. Educate the family to avoid sharing personal belongings. B. Ensure the state health department has been notified. C. Administer antitoxin. D. Assess for skin necrosis.

Correct Answer is B

Explanation

A. Lyme disease is primarily transmitted through ticks.

B. Lyme disease is a communicable disease of public concern and hence reportable

C. Incorrect. Antitoxin is not used for treating Lyme disease. Lyme disease is caused by a bacterium, not a toxin.

D. Incorrect. Skin necrosis is not a common manifestation of Lyme disease. The primary symptoms include fever, fatigue, headache, and a characteristic skin rash known as erythema migrans.

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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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