Sally is experiencing an exacerbation of symptoms of her schizophrenia. She tells you, her nurse, that the voices are getting louder and that they are telling her to "walk in front of a big truck."
Your first nursing action for Sally would be to:
A.
Divert her into a group activity immediately.
B.
Implement suicide precautions to keep her safe.
C.
Explain that there is nobody telling her to "walk in front of a big truck."
D.
Notify her family and ask them if she has said this before.
ANS: B
Auditory hallucinations telling a patient to harm herself require immediate intervention for safety, which would include suicide precautions so she is not left unsupervised. Distraction, determining past behavior, or challenging her thinking are not appropriate in this serious situation.
You might also like to view...
The goal of a bladder retraining program is to
a. Increase the older person's awareness of incontinent episodes b. Have the older person void every 2 hours c. Increase the period of time between voiding d. Increase the older person's awareness of the urge to void
When taking a 52-year-old's pulse rate, the nurse considers which of the following factors that might increase the client's pulse?(Select all that apply) Standard Text: Select all that apply
1. Age 2. Stress 3. Fever 4. Morning vital signs 5. Hemorrhage
The nurse is preparing a medication supplied in a powder form in a vial. Which information would the nurse require in order to prepare the medication to administer to the client? Select all that apply
1. Type of diluent needed 2. Amount of diluent to use to reconstitute the medication 3. The concentration of the medication once mixed 4. Actions and uses of the medication 5. Expiration date of the medication once it is reconstituted
An important component in the assessment of a client's skin is:
a. only performing a skin surface assessment b. always provide privacy during assessment c. allowing a client a choice in the areas for assessment d. removal of all clothing and sheets at the same time for a full body assessment