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 A

Explanation

A. Correct. Evaluating the client's ability to assist with repositioning is important to ensure safe and appropriate positioning that considers the client's capabilities and comfort.
B. Incorrect. The use of assistive devices or assistance from the nurse or other personnel may be necessary to ensure safe repositioning, especially in clients with mobility limitations.
C. Incorrect. While discussing the client's preferences is important, it may not directly relate to the immediate need for repositioning after a stroke.
D. Incorrect. Raising the side rails on both sides of the bed is important for client's safety, but it doesn't address the client's need for repositioning after a stroke.

A. Encourage clients to establish a timeline for their own grieving process. B. Initiate a discussion with clients about ways to cope with changes in family dynamics. C. Assist clients in identifying ways suicide could have been prevented. D. Discourage clients from sharing negative aspects of their relationship with the deceased persons.

Correct Answer is B

Explanation

A. Incorrect. Encouraging clients to establish a timeline for grieving might not be appropriate or helpful, as grief processes are individual and non-linear.
B. Correct. Coping with changes in family dynamics is a relevant topic for a support group of this nature, as suicide often brings significant family changes.
C. Incorrect. Focusing on preventing suicide is not the primary goal of this support group; coping and healing are more appropriate.
D. Incorrect. Allowing clients to share negative aspects of their relationship can promote emotional healing and understanding, which is essential in this context.

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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?

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