What intervention is a priority when the client is experiencing auditory hallucinations?

Determine what precipitates these hallucinations.

Distract the client when hallucinating.

Determine the content of the hallucinations.

Let the client know you do not hear the voices.

Answer and Explanation

The Correct Answer is C

A.   While understanding precipitating factors is important, it is not the immediate priority when the client is actively experiencing hallucinations.
B.   Distracting the client may not address the underlying cause of the hallucinations, which should be the priority.
C.   Determining the content of the hallucinations can provide important information for assessment and intervention.
D.   Dismissing the client's experience can be alienating and unhelpful.

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Correct Answer is ["B","C","D"]

Explanation

A) Incorrect. While it's important to avoid dehydration, this option is not specific to lithium use.

B) Correct. Lithium can cause dehydration, so it's crucial for the client to drink adequate fluids daily.

C) Correct. A low sodium diet is important while taking lithium, as high sodium levels can affect lithium absorption and potentially lead to toxicity.

D) Correct. Routine blood work is necessary to monitor lithium levels and ensure the client's levels remain within the therapeutic range.

E) Incorrect. Dependency is not a common concern with lithium.

A. Increase your fluid and fiber intake to prevent constipation. B. Have your blood pressure checked frequently for hypertension. C. Expect to have your blood checked weekly for serum electrolyte imbalances. D. Increase caloric intake to prevent weight loss. E. None F. None

Correct Answer is A

Explanation

A. Increase your fluid and fiber intake to prevent constipation – Risperidone, an atypical antipsychotic, can cause constipation due to its anticholinergic effects. Increasing fluid and fiber intake can help prevent this.
B. Have your blood pressure checked frequently for hypertension – Risperidone is more commonly associated with orthostatic hypotension, not hypertension.
C. Expect to have your blood checked weekly for serum electrolyte imbalances – Unlike clozapine, risperidone does not require frequent blood monitoring for electrolyte imbalances.
D. Increase caloric intake to prevent weight loss – Risperidone is more likely to cause weight gain rather than weight loss, so increasing caloric intake is unnecessary.

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What intervention is a priority when the client is experiencing auditory hallucinations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. What information should be included in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

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The nurse is building a discharge teaching plan with a client diagnosed with substance use disorder. Which of the following relapse prevention strategies will be included in the teaching? (Select all that apply)

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A client diagnosed with schizophrenia is experiencing delusions of persecution. How would the client express feeling persecuted?