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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect. While the client's sleep disturbance and lack of selfcare may contribute to
ineffective health maintenance, the more immediate concern is addressing the risk of imbalanced nutrition.
B) Incorrect. While clients in a manic state may exhibit hyperactivity and impulsivity, there is no indication in the scenario that the client poses an immediate risk for other-directed violence.
C) Correct. The client's reported lack of sleep and refusal to eat for an extended period raises concerns about nutritional deficits and dehydration. This is the most immediate and pressing issue to address.
D) Incorrect. While the client's manic state may increase the risk of impulsive behavior, there is no specific indication in the scenario that the client is at immediate risk for suicide.
Correct Answer is C
Explanation
A) Incorrect. Thyroxine is a hormone produced by the thyroid gland and is not directly implicated in the etiology of schizophrenia.
B) Incorrect. Erythropoietin is a hormone that stimulates the production of red blood cells and is not directly implicated in the etiology of schizophrenia.
C) Correct. Glutamate, an excitatory neurotransmitter, has been implicated in the development of schizophrenia. Abnormalities in glutamate signaling have been identified in individuals with schizophrenia.
D) Incorrect. While serotonin abnormalities have been associated with mood disorders such as depression, they are not considered a primary factor in the etiology of schizophrenia.
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