a client with schizophrenia is experiencing auditory hallucinations what is the most appropriate nursing intervention
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Nursing Elites

HESI LPN

HESI Mental Health

1. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

Correct answer: A

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.

2. What is the best initial action for the nurse to take with a manic depressive male client who becomes loud and verbally aggressive towards a nurse?

Correct answer: C

Rationale: In dealing with a manic depressive client who is being verbally aggressive, the best initial action for the nurse is to redirect the client by engaging him in a more constructive activity, such as playing card games with peers. This approach can help de-escalate the situation, shift the client's focus positively, and provide a distraction from the current behavior. Having the staff escort the client to his room may escalate the situation further. Threatening to record the behavior in his record is not likely to be effective in managing the immediate situation. Reviewing the medication record for an antipsychotic drug is important but would not be the best initial action in this scenario when the client is being verbally aggressive.

3. At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?

Correct answer: B

Rationale: The best response for the nurse is choice B: 'Yes, I will be leading this group. What would you like to accomplish during this time?' This response acknowledges the member's comment and encourages her to share her interests, promoting engagement and active participation in group activities. Choice A is not as inclusive and may not foster collaboration within the group. Choice C focuses more on the nurse's assignment rather than addressing the member's input. Choice D assumes emotions that were not expressed by the group member and does not encourage open communication.

4. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?

Correct answer: D

Rationale: A negative view of self and the future (D) is a prominent characteristic of depression. It reflects the core symptoms of low self-esteem and hopelessness that are commonly associated with this condition. Grandiose ideation (A) and suspiciousness of others (C) are more indicative of other mental health disorders like paranoia. While self-destructive thoughts (B) can be present in depression, they are not as specific and common as the negative self-view and hopelessness, making option (D) the most indicative characteristic of depression.

5. A client with schizophrenia is being treated with risperidone (Risperdal). The nurse notices that the client has a shuffling gait and tremors. What is the nurse's priority action?

Correct answer: A

Rationale: A shuffling gait and tremors may indicate extrapyramidal side effects (EPS) from risperidone. The nurse's priority action should be to administer an anticholinergic medication as it can help alleviate these symptoms associated with EPS. Documenting the findings and monitoring the client (Choice B) are important but addressing the immediate symptoms takes precedence. Assessing the client's blood glucose level (Choice C) is not directly related to the observed symptoms of shuffling gait and tremors. While notifying the healthcare provider (Choice D) is important, it is not the priority action when dealing with EPS symptoms.

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