NCLEX-RN · Question #444
A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
The correct answer is B. Attempts to direct the client's attention to the here and now. (A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is…
Question
A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
Options
- AEncourages the client to discuss the voices
- BAttempts to direct the client's attention to the here and now
- CExhibits sincere interest in the delusional voices
- DGives the medication as necessary for the acting-out behavior
How the community answered
(39 responses)- A5% (2)
- B72% (28)
- C15% (6)
- D8% (3)
Explanation
(A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.
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