A nurse is working with a patient diagnosed with schizophrenia who is experiencing auditory hallucinations. Which intervention best supports the patient in managing these symptoms?
Encourage the patient to argue with the voices to challenge their validity
Teach the patient distraction techniques, such as listening to music
Administer an additional dose of antipsychotic medication without consulting the prescriber
Advise the patient to ignore the hallucinations and focus on daily tasks
The Correct Answer is B
Choice A reason: Encouraging the patient to argue with auditory hallucinations can escalate distress and reinforce engagement with the voices, which is non-therapeutic in schizophrenia management. Evidence-based practice emphasizes reducing focus on hallucinations through coping strategies, not confrontation, making this choice incorrect.
Choice B reason: Teaching distraction techniques, like listening to music, is an evidence-based non-pharmacological intervention for managing auditory hallucinations. It helps shift attention away from the voices, reducing their intensity and promoting coping, aligning with psychiatric nursing principles, making this the correct choice.
Choice C reason: Administering an additional dose of antipsychotic medication without prescriber consultation violates nursing scope of practice and safety protocols. It risks toxicity and side effects, such as extrapyramidal symptoms, making this choice unsafe and incorrect for managing hallucinations.
Choice D reason: Advising the patient to ignore hallucinations is oversimplified and often ineffective, as it dismisses the distress caused by symptoms. This approach lacks therapeutic support and does not provide practical coping strategies, making it less appropriate than teaching distraction techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Role modeling involves demonstrating positive behaviors for others to emulate, often used in social learning. It does not involve applying negative stimuli like bitter substances to deter behaviors. Nail-biting treatment requires a direct intervention to discourage the habit, making this choice scientifically inappropriate.
Choice B reason: Aversion therapy uses an unpleasant stimulus, like a bitter substance, to create a negative association with an undesired behavior, such as nail-biting. This behavioral technique aims to reduce the behavior through conditioning, aligning with the described intervention, making this the correct choice for the therapy type.
Choice C reason: Milieu therapy focuses on creating a therapeutic environment to promote mental health, not targeting specific behaviors like nail-biting. It involves group dynamics and structured settings, not aversive stimuli. This approach is unrelated to the described intervention, making this choice incorrect.
Choice D reason: Desensitization therapy gradually exposes individuals to anxiety-provoking stimuli to reduce fear, commonly used for phobias. It does not involve aversive stimuli to deter behaviors like nail-biting. This therapy is unrelated to the described intervention, making it an incorrect choice for this scenario.
Correct Answer is A
Explanation
Choice A reason: Zolpidem, a nonbenzodiazepine sedative, affects the central nervous system, causing sedation and impaired coordination, particularly in the elderly. Age-related declines in metabolism and balance increase fall risk, a critical nursing consideration. Monitoring mobility and ensuring safety measures are essential to prevent injuries, making this the correct choice.
Choice B reason: While zolpidem may cause daytime drowsiness, this is not the primary nursing consideration compared to fall risk in the elderly. Drowsiness is a general side effect, but the elderly’s heightened vulnerability to falls due to sedation and impaired coordination takes precedence, making this choice less critical.
Choice C reason: Zolpidem has a lower dependence risk than benzodiazepines, and dependence is not inevitable. This assumption overstates the risk and is not the primary nursing consideration. Fall prevention, especially in vulnerable populations like the elderly, is more urgent due to immediate safety concerns, making this choice incorrect.
Choice D reason: Zolpidem induces sedation rapidly, typically within 15–30 minutes, not requiring 4 weeks. This choice is factually incorrect, as prolonged use is not necessary for efficacy. The primary concern is immediate side effects like falls, not a delayed onset, making this an invalid nursing consideration.
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