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 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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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

A. Check the bruises at the next visit to the client's home. B. Follow the agency's guidelines for reporting suspected abuse. C. Institute more frequent visits to the client's home. D. Arrange referral for family therapy to deal with home stressors.

Correct Answer is B

Explanation

A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.

B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.

C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.

D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.

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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 group of clients in a mental health facility. Which of the following clients recommend the physician or nurse practioner see first?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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