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

Answer and Explanation

The Correct Answer is D

A. Setting limits on the amount of time the client talks about delusions (option A) is not the most therapeutic approach. While it's important to redirect the client and encourage engagement in reality-based discussions, setting strict time limits may feel punitive and hinder the therapeutic relationship.

B. Scheduling a variety of competitive, stimulating group activities for the client (option B) may be overwhelming for someone experiencing paranoid delusions. It's essential to create a supportive and non-threatening environment.

C. Telling the client that the delusions are not real (option C) is generally not effective and can be counterproductive. Individuals with schizophrenia often have a strong belief in the reality of their delusions, and direct confrontation can lead to resistance and mistrust.

D. Avoiding asking the client about triggers for the delusions (option D) is a reasonable approach. Pressing the client for information about their delusions may increase anxiety and paranoia. It's more appropriate to build a trusting relationship before exploring potential triggers. As the therapeutic relationship develops, exploring triggers can be part of a comprehensive care plan.

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Correct Answer is ["B","D","E"]

Explanation

The "3" findings that should indicate to the nurse that the client is experiencing negative symptoms related to their schizophrenia are:
B.Lack of motivation
D.Lack of energy
E.Withdrawn
Explanation:
Negative symptoms in schizophrenia involve deficits or reductions in normal emotional and behavioral functioning. In the provided nurse's notes:

Blood pressure: Blood pressure is not mentioned in the nurse's notes, and it is not directly indicative of negative symptoms in schizophrenia.

B. Lack of motivation: The client refusing to eat or drink, not engaging in conversation, and not wanting to go to therapy sessions are indicative of a lack of motivation, which is a negative symptom.

C. Change in behavior: While there is a change in behavior mentioned in the notes (refusing to eat or drink, not engaging in conversation), the specific behavioral changes described are more closely associated with negative symptoms. Negative symptoms involve a reduction or loss of normal functions.

D. Lack of energy: The client's slow movements and desire to sleep suggest a lack of energy, another negative symptom associated with schizophrenia.

E. Withdrawn: The client's withdrawal from social interaction, as evidenced by not engaging in conversation and wanting to sleep, is characteristic of withdrawal, which is a negative symptom.

A. Dental caries B. Perforation of nasal septum C. Permanent effects on short-term memory loss D. Pancreatitis

Correct Answer is B

Explanation

A. Dental caries is not a specific complication commonly associated with heroin use. Dental issues may result from other substances or lifestyle factors.

B. Perforation of the nasal septum is a complication associated with the intranasal use of heroin. Chronic snorting or sniffing of heroin can damage the nasal septum, leading to a perforation.

C. Permanent effects on short-term memory loss are more commonly associated with the use of substances like cannabis or certain hallucinogens. Heroin use is not typically linked to permanent effects on short-term memory.

D. Pancreatitis is not a commonly reported complication of heroin use. Pancreatitis is more commonly associated with alcohol use disorder and gallstone-related issues.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia. Exhibits Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.

Correct Answer is ["B","D","E"]

Explanation

A nurse is assisting in the development of a community education course about the physical complications related to substance use disorder. Which of the following complications should the nurse include in the discussion about heroin use?

Correct Answer is B

Explanation

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

A nurse is reinforcing teaching with a client who takes diazepam (Valium). Which of the following information should the nurse include?

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?