A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Tell the client that there is nothing there.

Ask the client to describe what is being seen.

Touch the client's arm reassuringly.

Remove the client from the room.

Answer and Explanation

The Correct Answer is B

A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.

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Correct Answer is C

Explanation

A. Histrionic personality disorder: Individuals with this disorder exhibit excessive emotionality and attention-seeking behavior but are not typically aggressive or violent. Their actions are more dramatic and flirtatious rather than physically confrontational.
B. Borderline personality disorder: This condition is marked by unstable relationships, intense emotions, and impulsivity, but aggression in public settings is not a primary characteristic. Self-harm or intense emotional reactions are more common.
C. Antisocial personality disorder: This disorder involves a disregard for societal rules, impulsivity, and aggressive behavior. Clients often engage in criminal activities, violate others' rights, and show little remorse for their actions, making them more likely to have altercations requiring law enforcement intervention.
D. Narcissistic personality disorder: Individuals with this disorder display an exaggerated sense of self-importance and a need for admiration but are not typically physically aggressive. They may become verbally demeaning when their ego is challenged but do not frequently engage in law-breaking behavior.

A. When attending dialectical behavior therapy B. When getting married C. When discharged from the hospital D. When attending narrative therapy

Correct Answer is C

Explanation

A. "When attending dialectical behavior therapy." Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder (BPD) manage emotions and reduce self-harming behaviors. While therapy can bring up distressing emotions, it provides structured support and coping strategies. The risk of self-harm is lower when clients are actively engaged in treatment and receiving professional guidance.
B. "When getting married." Major life changes, including marriage, can be stressful for individuals with BPD, but they do not inherently pose the highest risk for self-harm. Support from a partner and structured therapy can help navigate emotional challenges. While instability in relationships can trigger distress, the protective factors of marriage may reduce immediate risk. Self-harm risk is typically higher in periods of transition without support.
C. "When discharged from the hospital." Clients with BPD often struggle with emotional regulation, and discharge represents a significant transition with decreased support. The sudden loss of a structured inpatient setting can increase feelings of abandonment and distress, leading to a heightened risk of self-harm. Ensuring a follow-up care plan and support system is crucial to reducing this risk after hospitalization.
D. "When attending narrative therapy." Narrative therapy helps clients reframe their experiences and build a stronger sense of identity. Although deep emotional topics may be explored, structured therapy provides a safe space for expression. Therapeutic interventions aim to reduce distress and teach coping mechanisms, decreasing the likelihood of self-harm. The highest risk occurs when structured support is suddenly removed.

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A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Nursing Test Bank

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