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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale:
Increased water intake is not a specific teaching point for fluoxetine. While general hydration is important for overall health, it's not directly related to the medication's effectiveness or side effects.
Fluoxetine is not known to cause dehydration or require fluid intake beyond typical recommendations.
Focusing on water intake could potentially distract from more relevant education about the medication.
Choice B rationale:
Sedation and sleepiness are common side effects of fluoxetine, especially during the initial weeks of treatment.
It's important for the client to be aware of these potential side effects so they can make necessary adjustments to their activities, such as avoiding driving or operating machinery if drowsy.
Understanding that these side effects are expected can also help with adherence to treatment, as clients may be less likely to discontinue the medication if they know that the side effects are likely to subside over time.
Choice C rationale:
Fluoxetine can sometimes cause sexual side effects, such as decreased libido or difficulty achieving orgasm.
It's important for the client to be aware of this potential side effect, but it's not accurate to say that they will definitely notice an improvement in their sex drive.
Sexual side effects can be distressing and may impact treatment adherence, so open communication with the healthcare provider is essential if these issues arise.
Choice D rationale:
Fluoxetine can take several weeks, typically 4-6 weeks, to fully exert its therapeutic effects.
Expecting to feel better within 3-4 days could lead to disappointment and frustration if symptom improvement isn't immediately noticeable.
It's important for the client to understand that patience is needed while the medication takes effect.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.