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 D

Explanation

Choice A rationale:

An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.

Choice B rationale:

An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.

Choice C rationale:

Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.

Choice D rationale:

A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.

A. difficulty sleeping B. frequent headaches C. feeling much better D. less fatigue

Correct Answer is ["A","B"]

Explanation

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

Explanation:

Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):

Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Correct Answer is D

Explanation

Correct Answer is ["A","B"]

Explanation

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