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 C

Explanation

A. Foods that are high in dietary tyramine are more relevant to certain antidepressant medications, particularly monoamine oxidase inhibitors (MAOIs), and are not a specific concern with alprazolam.

B. Increasing the dose of the medication without consulting the healthcare provider is not appropriate. Adjustments to the dosage should be done under the guidance of the healthcare provider.

C. Avoid driving or operating heavy machinery until you know how alprazolam affects you.
This is an important safety consideration when using benzodiazepines such as alprazolam. Benzodiazepines can cause drowsiness and impair coordination, so clients should be advised to avoid activities that require mental alertness, such as driving or operating machinery, until they are aware of how the medication affects them.

D. Manifestations of anxiety should improve with the use of alprazolam, and relief of symptoms can occur relatively quickly. However, it is essential to inform the client that long-term use of benzodiazepines may lead to tolerance and dependence. They should not abruptly stop the medication without consulting their healthcare provider.

A. Grandiosity B. Clang associations C. Flight of ideas D. Confabulation

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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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 is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

Correct Answer is C

Explanation

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

Correct Answer is A

Explanation

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

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?

A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

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A nurse is reinforcing teaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching?

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?