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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering diazepam may be part of the treatment plan for delirium tremens, but ensuring adequate hydration and addressing potential electrolyte imbalances is the first priority.
B. Raising the side rails is important for safety, but it is not the highest priority action at this time.
C. Obtaining a medical history is important for comprehensive care, but in this urgent situation, addressing fluid and electrolyte balance is the first priority.
D. Starting intravenous fluids is crucial for rehydration and addressing potential electrolyte imbalances, which is the priority in this emergency situation.
Correct Answer is D
Explanation
A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.
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