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","D","E"]

Explanation

A. Nylon socks. Nylon socks do not pose a significant risk for self-harm and can be safely kept with the client. They are not considered a ligature risk or a hazardous object.
B. Cotton underwear. Cotton underwear is not a safety concern in a mental health unit. It does not present a strangulation risk or any other immediate danger.
C. Lace-up tennis shoes. Lace-up shoes contain long laces that could be used as a ligature, posing a strangulation risk. Clients in a mental health unit are typically provided with slip-on or Velcro shoes to enhance safety.
D. Glass-framed picture of the client's partner. A glass frame poses a significant risk as it can be broken and used as a sharp object for self-harm. The nurse should ask the partner to take it home or provide a safer alternative, such as a laminated photo.
E. Necklace. A necklace can be used for strangulation, making it unsafe for a client at risk of self-harm. Removing items that could be used for ligature or harm is essential in suicide prevention.

A. Engaging in extracurricular activities B. Loss of a job C. Financial stability D. Exercising caution in behavior

Correct Answer is B

Explanation

A. Engaging in extracurricular activities. Participating in extracurricular activities is generally associated with social support and positive mental health. Individuals involved in structured activities often have a sense of purpose and connection, which can be protective against suicide rather than a risk factor.
B. Loss of a job. Job loss is a significant risk factor for suicide due to its impact on financial stability, self-esteem, and emotional well-being. Unemployment can lead to feelings of hopelessness, social isolation, and increased stress, all of which contribute to a higher suicide risk.
C. Financial stability. Financial stability generally reduces stress and provides security, lowering the likelihood of suicidal ideation. While financial difficulties can be a risk factor, having stable finances is not associated with increased suicide risk.
D. Exercising caution in behavior. Practicing caution in behavior reflects awareness of potential dangers and a tendency to avoid reckless or impulsive actions. Individuals who take precautions in their daily lives are less likely to engage in high-risk behaviors that could lead to suicide.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D","E"]

Explanation

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Explanation

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