Psychotic Disorders no. 4101

Psychotic Disorders no. 4101

QUESTION: The nurse is monitoring a client who appears to be hallucinating. The nurse notes paranoid content in the client's speech, and he appears agitated. The client is gesturing at a figure on the television. Which nursing interventions are appropriate? Select all that apply:

✘O a.)In a firm voice, instruct the client to stop the behavior.
✓O b.) Reinforce that the client is not in any danger.
✓O c.)Acknowledge the presence of the hallucinations.
✘O d.)Instruct other team members to ignore the client's behavior.
Immediately implement physical restraint procedures.
Use a calm voice and simple commands.

RATIONALE

RATIONALE: Using a calm voice, the nurse should reassure the client that he is safe. The nurse shouldn't challenge the client; rather, she should acknowledge his hallucinatory experience. It isn't appropriate to request that the client stop the behavior. Implementing restraints isn't warranted at this time. Although the client is agitated, no evidence exists that the client is at risk for harming himself or others.
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application