Practice Quiz

NCLEX-PN

Category - Psychosocial Integrity

Start a Study Session Sign up for Question of the Day
The nurse in a mental health facility is caring for a female client noted to have hallucinations and irrational beliefs on assessment. One afternoon, the nurse notes that the client appears severely agitated as she watches a television show in the dayroom. It appears that the client is experiencing active hallucinations. Which of the following interventions is the least appropriate?
  1. The nurse acknowledges the hallucination experience, but reinforces reality
  2. Instruct the client to stop the behavior in a firm yet kind and calm voice
  3. Inform the client that he is in a safe environment
  4. Avoid the use of physical and chemical restraints
Explanation
Answer: B - In the presence of active hallucinations, instructing the client to stop the behavior is the least appropriate intervention. This nursing action is challenging the client’s experience, which is non-therapeutic. Restraints are only considered if the client poses harm to self and to others. The other options are appropriate.
Was this helpful? Upvote!
Login to contribute your own answer or details
Start a Study Session Sign up for Question of the Day

Top questions

Related questions

Most popular on PracticeQuiz