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 A

Placing the client in seclusion if she is experiencing visual hallucinations is not a recommended intervention. Seclusion can be isolating and distressing for the client, and it may make the hallucinations worse. It should only be used as a last resort when other interventions have failed to keep the client safe.

Here are some of the reasons why seclusion is not a recommended intervention for clients with schizophrenia who are experiencing visual hallucinations:

It can increase the client's anxiety and agitation.

It can make the client feel more isolated and alone.

It can make the client feel like they are being punished.

It can make the client less likely to trust the staff.

It can interfere with the client's treatment and recovery.

It is important to note that there are some situations where seclusion may be necessary, such as when the client is at risk of harming themselves or others. However, it should only be used as a last resort and for the shortest amount of time possible.

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Correct Answer is D

Explanation

Choice A rationale:

Mental separation from distractions during painting is a healthy coping mechanism, allowing for focus and mindfulness.

It falls under the adaptive defense mechanism of compartmentalization, which involves temporarily separating thoughts and emotions to manage stress effectively.

It doesn't deny or distort reality, but rather creates a temporary mental space for relaxation and creativity.

Choice B rationale:

Writing a short story about a heroic woman is a form of sublimation, channeling negative emotions into a productive and creative outlet.

It's a mature defense mechanism that allows for indirect expression of anger or frustration without causing harm to oneself or others.

It can lead to personal growth and insight, as it encourages reflection and exploration of emotions through storytelling.

Choice C rationale:

Inability to recall the scene of a traumatic event is likely a dissociative defense mechanism, protecting the individual from overwhelming psychological distress.

It's a common response to trauma, and while it may be maladaptive in the long term if it prevents processing the trauma, it serves a protective function in the acute phase.

It doesn't necessarily indicate a maladaptive coping style overall, but rather a specific response to a traumatic experience.

Choice D rationale:

Declaring disinterest in work after being denied a promotion exemplifies disengagement, a maladaptive coping mechanism involving withdrawal and apathy.

It reflects an inability to cope with disappointment or setbacks in a constructive way.

It can lead to social isolation, decreased motivation, and potentially depression or other mental health issues.

A. “You will remain asleep for about 2 hours after the procedure.” B. “These treatments should cure your depression.” C. “You will receive a medication to prevent seizure activity.” D. “You might experience some temporary memory loss after the procedure.”

Correct Answer is D

Explanation

A rationale:

Incorrect. While patients typically do sleep for a period after ECT, the duration is usually shorter, around 30-60 minutes.

Providing inaccurate information about the length of sleep can lead to confusion and anxiety for the patient.

Evidence: Studies have shown that the average recovery time following ECT is around 30-60 minutes, with most patients feeling alert and oriented within that time frame. (Source: NIH.gov) Choice B rationale:

Incorrect. While ECT can be highly effective in treating depression, it is not considered a cure. It's important to manage expectations and emphasize that ECT is a treatment option that can significantly improve symptoms but may not guarantee a complete cure.

Evidence: Research indicates that ECT has a remission rate of approximately 50-70% in patients with severe depression, meaning that many patients experience a significant reduction or disappearance of symptoms. However, relapse rates can range from 30-50%, indicating that ongoing maintenance treatment is often necessary. (Source: American Psychiatric Association)

Choice C rationale:

Incorrect. Muscle relaxants, not seizure-preventing medications, are administered during ECT to protect the patient from injury during the induced seizure. It's crucial to clarify this distinction to avoid misunderstandings about the procedure's mechanism of action.

Evidence: Standard ECT protocols involve the use of a short-acting muscle relaxant, such as succinylcholine, to prevent muscle contractions during the seizure. This helps to minimize the risk of physical injury and ensure patient safety. (Source: Healthline.com)

Choice D rationale:

Correct. Temporary memory loss is a common side effect of ECT, and it's essential to inform patients about this potential issue to prepare them for the experience and address any concerns they may have.

Evidence: Studies have shown that approximately 40-50% of patients experience some degree of memory impairment following ECT, primarily affecting short-term memory of events occurring around the time of treatment. However, this memory loss is usually temporary and resolves within a few weeks or months for most patients. (Source: Studocu.com)

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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?