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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fluoxetine. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety, and obsessive-compulsive disorder. It does not alleviate tardive dyskinesia symptoms and is not indicated for managing extrapyramidal side effects.
B. Diphenhydramine. Diphenhydramine is an antihistamine that can help with acute dystonic reactions due to its anticholinergic effects, but it does not treat tardive dyskinesia. Long-term use may even worsen movement disorders.
C. Naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose. It has no effect on tardive dyskinesia, as this condition is related to prolonged dopamine receptor blockade rather than opioid activity.
D. Valbenazine. Valbenazine is a vesicular monoamine transporter 2 (VMAT2) inhibitor specifically approved for the treatment of tardive dyskinesia. It helps regulate dopamine release and reduces involuntary movements associated with the condition.
Correct Answer is D
Explanation
A. Preparation: In this stage, individuals recognize the need for change and start making plans, such as gathering information or setting goals. The client, however, shows no intent to change dietary habits.
B. Action: This stage involves actively modifying behaviors and consistently implementing changes. The client is not taking any steps toward dietary adjustments, indicating they are not in this stage.
C. Contemplation: Individuals in this stage acknowledge the need for change and consider making adjustments but have not yet committed. The client, by dismissing the information, is not showing contemplation.
D. Precontemplation: This stage is characterized by a lack of awareness or denial of the need for change. The client’s response suggests they do not see dietary restrictions as necessary and are resistant to modifying their eating habits.
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