A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior.
Which of the following interventions should the nurse recommend to be included in the plan of care?

Place the client in seclusion if she is experiencing visual hallucinations.

Minimize staff supervision of the client’s interactions with others.

Directly tell the client that delusions are not real.

Limit the client’s participation in group activities.

Answer and Explanation

The Correct Answer is D

The correct answer is D. Limit the client’s participation in group activities.

Explanation:

Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.

Why the other options are incorrect:

A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.

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Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

Having consistent unit routines can provide a sense of stability and predictability, which can be beneficial for a client in the manic phase of bipolar disorder.

Choice B rationale:

Providing a stimulating environment can potentially exacerbate symptoms of mania, making it an inappropriate intervention.

Choice C rationale:

Scheduling daily seclusion times is not typically recommended as it can lead to feelings of isolation.

Choice D rationale:

Discouraging daytime napping can potentially lead to fatigue and worsen symptoms, so it’s not typically recommended.

A. “I tense and release my muscles, starting with my feet.” B. “I sleep in in the mornings.” C. “I think about being on my favorite beach vacation.” D. “I isolate myself in my room for a few hours when things get overwhelming.” E. Social support

Correct Answer is ["A","E"]

Explanation

Choice A rationale:

Progressive muscle relaxation (PMR) is a well-established technique for stress reduction. It involves systematically tensing and releasing different muscle groups throughout the body. This process helps to release physical tension, promote relaxation, and decrease feelings of stress and anxiety.

PMR has been shown to be effective in reducing stress and anxiety in various populations, including individuals with chronic pain, anxiety disorders, and sleep difficulties.

It is a simple, safe, and accessible technique that can be practiced independently without any special equipment or training.

Choice B rationale:

While sleeping in can provide temporary relief from stress, it is not considered an adaptive coping strategy in the long term.

Oversleeping can disrupt sleep patterns and circadian rhythms, which can actually worsen stress and anxiety in the long run.

It can also lead to social isolation and decreased productivity, further compounding stress.

Choice C rationale:

While distraction techniques, such as thinking about a favorite vacation, can provide temporary relief from stress, they do not address the underlying causes of stress.

Overreliance on distraction can prevent individuals from developing more effective coping strategies for managing stress in the long term.

Choice D rationale:

Social isolation is generally considered a maladaptive coping strategy. While it may provide temporary relief from overwhelming situations, it can lead to increased feelings of loneliness, disconnection, and rumination.

It can also prevent individuals from seeking support and developing more effective coping strategies.

Choice E rationale:

Social support is a crucial factor in stress management. Connecting with supportive friends and loved ones can provide emotional comfort, reduce feelings of isolation, and promote a sense of belonging.

Positive social interactions can also buffer the negative effects of stress and promote resilience.

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A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior. Which of the following interventions should the nurse recommend to be included in the plan of care?

Explanation:

Why the other options are incorrect:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

Correct Answer is A

Explanation

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

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A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior.
Which of the following interventions should the nurse recommend to be included in the plan of care?