The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
tells the client that others see or hear what he does
distracts the client by placing him in the dayroom with others
asks the client if he hears voices telling him to harm himself or others
goes along with what the client says to decrease the risk of increasing the client’s anxiety
Numbers 1 and 5 are correct.
During an active hallucination, safety is the first priority. The nurse should administer medications as ordered to manage the hallucinations. Asking the client if he hears voices telling him to harm himself or others is important for both client and nurse safety, as well as others in the area. A client having hallucinations should not be touched. The nurse should not tell the client that others are experiencing the same thing as this only reinforces the hallucination and false beliefs. The client should be moved to an area with decreased stimuli, not taken to the dayroom with others. The nurse should gently attempt to reorient the client to reality. Going along with what the client says he is experiencing reinforces false beliefs and interferes with reorienting the client to reality.
