Page 2295 - Saunders Comprehensive Review For NCLEX-RN

Reference: Varcarolis (2017), p. 379.

813. Answer: 3

Rationale: The risk for impulsive and aggressive behavior may increase if a client
is receiving command hallucinations to harm self or others. If the client is
experiencing a hallucination, the nurse or health care counselor, not a friend, should
be contacted to discuss whether the client has intentions to hurt herself or himself or
others. Talking about auditory hallucinations can interfere with subvocal muscular
activity associated with a hallucination. The client statements in the remaining
options will aid in wellness but are not specific interventions for hallucinations, if
they occur.
Test-Taking Strategy: Note the strategic words, need for additional information.
These words indicate a negative event query and the need to select the incorrect
statement as the answer. Focus on the subject, managing hallucinations and anxiety.
The correct option is a specific agreement to seek appropriate help. The remaining
options are interventions that a client can carry out to aid wellness.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Teaching and Learning
Content Area: Mental Health
Health Problem: Mental Health: Schizophrenia
Priority Concepts: Client Education; Safety
Reference: Varcarolis (2017), pp. 256-257.

814. Answer: 3

Rationale: Clients who are withdrawn may be immobile and mute and may
require consistent, repeated approaches. Communication with withdrawn clients
requires much patience from the nurse. Interventions include the establishment of
interpersonal contact. The nurse facilitates communication with the client by sitting
in silence, asking simple open-ended questions rather than direct questions, and
pausing to provide opportunities for the client to respond. Although overstimulation
is not appropriate, there is no therapeutic value in ignoring the client. The client’s
safety is not the responsibility of other clients.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate options
either that are nontherapeutic or could result in overstimulation. Also eliminate
options that are not examples of therapeutic communication. The correct option
provides for client supervision and communication as appropriate.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Schizophrenia
Priority Concepts: Caregiving; Psychosis
Reference: Varcarolis (2017), p. 251.

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