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 D

Explanation

A. This response may be seen as evading the client's statement. It's important to provide a more direct response.
B. This response may come across as controlling or confrontational, which may not promote open communication.
C. This response is a good therapeutic technique as it encourages the client to reflect on past experiences with stopping medication.
D. This response provides a clear and factual statement about the purpose of the prescribed medication, encouraging the client to understand its importance.

A. Orienting the client to the unit B. Reinforcing reality with the client C. Establishing a nonthreatening relationship D. Assessing the client for physical problems

Correct Answer is D

Explanation

A. Orienting the client to the unit While orientation is important, the client's prolonged
immobility and stupor necessitate a physical assessment first to ensure there are no underlying medical issues contributing to this state.

B. Reinforcing reality with the client The client's catatonic state may make it difficult to effectively communicate or engage in reality orientation at this point. Addressing potential physical issues is the initial priority.

C. Establishing a nonthreatening relationship Building a therapeutic relationship is crucial, but given the client's current state, assessing for physical problems takes precedence.

D. Assessing the client for physical problems The client's prolonged catatonic state requires an
immediate physical assessment to rule out any underlying medical conditions contributing to his condition.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

Correct Answer is D

Explanation

A 28-year old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

Correct Answer is D

Explanation

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