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    Ati Lpn Comprehensive Predictor 2023 Proctored Exam

    A nurse is assisting with the care of a client who has schizophrenia and is actively hallucinating. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Avoid attempting to distract the client away from the hallucination: While it is important not to reinforce hallucinations, gentle redirection or distraction can help the client focus on reality and reduce distress. Avoiding all attempts at distraction may increase anxiety or withdrawal. B. Encourage group activities: Clients actively experiencing hallucinations may have difficulty concentrating or interacting safely in a group setting. Encouraging participation at this time could increase agitation or confusion. Individualized, low-stimulation interventions are preferable. C. Provide low lighting in the client's room: Low, soft lighting reduces environmental stimuli that can exacerbate hallucinations or agitation. Creating a calm, quiet environment supports reality orientation and helps the client manage sensory overload. D. Use touch to convey acceptance: Physical touch may startle, confuse, or distress a client experiencing hallucinations. Safety and personal boundaries should be maintained, and touch should generally be avoided unless the client initiates or clearly consents.

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