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 B
Explanation
Choice A rationale:
Monitoring the client closely to prevent self-mutilation is more associated with self-harm disorders rather than dependent personality disorder.
Choice B rationale:
Giving positive feedback when the client is assertive with staff or clients can encourage independence and confidence.
Choice C rationale:
Discouraging flamboyant or seductive behaviors is more related to histrionic personality disorder.
Choice D rationale:
Setting limits to prevent exploitation of other clients is more associated with antisocial personality disorder.
Correct Answer is C
Explanation
Choice A rationale:
Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.
Choice B rationale:
Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.
Choice C rationale:
Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.
Choice D rationale:
Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.
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