Practice Quiz

NCLEX-PN

Category - Psychosocial Integrity

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The nurse is caring for a 50-year-old female client who is admitted with active auditory hallucinations and delusions of persecution. The nurse observes that the client is demonstrating signs of agitation. Which of the following nursing actions is the least appropriate at this time?
  1. The nurse avoids touching the client
  2. The nurse acknowledges the hallucination experience
  3. Initiate reality-oriented activities
  4. Assure the client that she is in a safe place
Explanation
Answer: C - Reality-oriented activities are not initiated when the client’s anxiety level is escalating. This technique may further agitate the client. Avoidance of touch, acknowledging the hallucination experience, and assuring the client that she is in a safe place are therapeutic.
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