Psychotic Disorders no. 4066

Psychotic Disorders no. 4066

QUESTION: A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:

✘O a.) take the client's vital signs.
✓O b.) explore the content of the hallucinations.
✘O c.) tell him his fear is unrealistic.
✘O d.) engage the client in reality-oriented activities.

RATIONALE

RATIONALE: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities.
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis