A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior.
Which of the following interventions should the nurse include in the initial plan?
Warn the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination.
Keep the facility’s security personnel constantly visible to the client throughout treatment.
Collaborate with the client to develop a daily physical exercise routine.
Agree that the hallucinations are real if the client exhibits aggressive behavior toward other clients.
The Correct Answer is C
Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.
Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.
Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.
Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.
The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
Correct Answer is B
Explanation
Encourage the client to visit with someone who has had an amputation.
This strategy can help the client cope with the loss of a body part and learn from the experience of others who have gone through a similar situation.
Choice A is wrong because suggesting that the client wear facility clothing until the prosthesis fitting can delay the client’s acceptance of the body image alteration and increase the risk of infection.
Choice C is wrong because discouraging the client from touching the residual limb for the first week can interfere with the healing process and prevent the client from becoming familiar with the new body part.
Choice D is wrong because reassuring the client that the rehabilitation program is optional can discourage the client from participating in physical therapy and hinder the recovery and adaptation.
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