A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?
Set limits on the amount of time the client talks about delusions,
Schedule a variety of competitive stimulating group activities for the client
Tell the client that the delusions are not real
Avoid asking the client about triggers for the delusions
The Correct Answer is A
A. Set limits on the amount of time the client talks about delusions. Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.
B. Schedule a variety of competitive stimulating group activities for the client. Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.
C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.
D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.
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Related Questions
Correct Answer is B
Explanation
A. A client taking olanzapine who experiences dizziness upon standing: While dizziness is a potential side effect, it is not as immediately concerning as the symptoms in the client taking clozapine. Orthostatic hypotension is a known side effect of some antipsychotic medications, and the client may need to be assessed for orthostatic changes.
B. A client taking clozapine who has a sore throat and mild fever.
Clozapine is an atypical antipsychotic that can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. A sore throat and mild fever can be early signs of infection, and it's crucial to evaluate the client promptly for any indications of agranulocytosis. Regular monitoring of complete blood counts is essential for clients taking clozapine.
C. A client taking risperidone who has gained 5 lb in 3 weeks: Weight gain is a side effect of many antipsychotic medications, including risperidone. While it's important to monitor weight changes, gaining 5 lb in 3 weeks is not as urgent as potential signs of agranulocytosis in the client taking clozapine.
D. A client taking chlorpromazine who is napping frequently throughout the day: Frequent napping may be related to sedation, a common side effect of chlorpromazine. While it's important to assess and address sedation, it is not as urgent as potential signs of infection or agranulocytosis in the client taking clozapine
Correct Answer is A
Explanation
A. Grandiosity.
Grandiosity is a symptom commonly seen in the manic phase of bipolar disorder. It involves an inflated sense of self-importance, unrealistic beliefs in one's abilities, and a perception of being involved in activities that are revolutionary or of great significance. In this scenario, the client's statement about revolutionizing the industry reflects grandiosity.
B. Clang associations involve the association of words based on sound rather than meaning and are often seen in individuals with thought disorders.
C. Flight of ideas refers to a rapid flow of thoughts, often manifested by speech that is difficult to interrupt, with topics changing rapidly.
D. Confabulation is the creation of false or distorted memories without the intention to deceive. It is not a characteristic behavior of mania in bipolar disorder.
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