A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.
Which of the following is the priority nursing intervention for this client?
Ensure the client goes to group activities as planned.
Use distraction such as the television or music.
Provide reassurance and comfort ensuring the client is safe.
Give PRN medications to treat increased hallucinations.
The Correct Answer is C
Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Command hallucinations can direct the patient to harm themselves or others, making it the priority to address.
Choice B rationale:
Tactile hallucinations, while distressing, are not typically as immediately dangerous as command hallucinations.
Choice C rationale:
Gustatory hallucinations, while potentially disturbing, do not usually pose an immediate threat.
Choice D rationale:
Visual hallucinations, while potentially distressing, are not typically as immediately dangerous as command hallucinations.
Correct Answer is D
Explanation
Choice A rationale:
Diarrhea is not a specific reason to stop lithium. However, severe diarrhea can affect lithium levels and should be reported to a healthcare provider.
Choice B rationale:
Lithium does not need to be taken on an empty stomach. It can be taken with or without food.
Choice C rationale:
A low-salt diet is not recommended while on lithium. In fact, a consistent, normal sodium intake is important because low sodium levels can cause lithium levels to become too high.
Choice D rationale:
Regular blood tests are necessary when taking lithium to ensure therapeutic levels and prevent toxicity. Weekly blood tests may be required during the first month of treatment.
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