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 A
Explanation
Choice A reason: Peplau’s interpersonal relations theory emphasizes the nurse-patient relationship as a therapeutic tool. Reflecting on interactions helps nurses understand dynamics, build trust, and adjust approaches, fostering therapeutic growth, making this the correct choice aligned with her theory.
Choice B reason: Administering medications is a clinical task, not a core component of Peplau’s theory, which focuses on interpersonal dynamics. While important, it does not directly enhance the therapeutic relationship, making this choice incorrect for the theory’s focus.
Choice C reason: Documenting behaviors is standard practice but not central to Peplau’s theory, which prioritizes relational dynamics over administrative tasks. Documentation supports care but does not foster interpersonal growth, making this choice incorrect for the theory.
Choice D reason: Teaching coping skills is therapeutic but secondary to Peplau’s focus on the nurse-patient relationship itself. Reflection on interactions directly supports the theory’s emphasis on understanding relational dynamics, making this choice less relevant than self-reflection.
Correct Answer is B
Explanation
Choice A reason: Suggesting the adolescent share with the psychiatrist avoids the nurse’s duty to report imminent threats. Ethical and legal standards require immediate action for safety, making this response inadequate, as it delays intervention in a potential crisis.
Choice B reason: Reporting a threat to harm others is a legal and ethical duty in psychiatric nursing, as it indicates imminent danger. Sharing with the team ensures safety interventions, aligning with mandatory reporting laws, making this the correct response.
Choice C reason: Discussing feelings is therapeutic but does not address the immediate safety risk of a threat. Prioritizing exploration over reporting violates ethical standards for managing dangerous behaviors, making this response incorrect in this context.
Choice D reason: Promising confidentiality in the face of a threat violates nursing ethics and legal mandates to report harm risks. This undermines patient and public safety, making it a non-therapeutic and incorrect response to a serious threat.
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