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 C
Explanation
A. "Everyone has trouble sleeping at times" minimizes the client's concerns and may not address the underlying issues contributing to their anxiety.
B. "Why do you think you are so anxious?" might come across as judgmental or confrontational, and it may not create a supportive environment for the client to open up about their feelings.
C. "Have you talked to your provider about this yet?"
This response encourages the client to seek professional help and addresses the issue of increasing anxiety and difficulty sleeping. It is supportive and guides the client toward discussing their concerns with a healthcare provider who can assess the situation and provide appropriate interventions.
D. "It sounds like you're having a difficult time" acknowledges the client's distress but does not guide them toward seeking professional help. Encouraging a conversation with a healthcare provider is a more direct and helpful approach.
Correct Answer is C
Explanation
A. Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia.
B. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation.
C. Pupillary constriction (miosis).
Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness.
D. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.
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