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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Justice is the ethical principle of treating the patient fairly and equally among staff when making assignments. The charge nurse is upholding this principle by ensuring that the workload is distributed evenly and that no staff member is overburdened or underutilized.

Choice A is wrong because Veracity is wrong because veracity is the ethical principle of telling the truth to the patient.

This principle is not relevant to the scenario of making assignments.

Choice C is wrong because Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own healthcare decisions.

This principle is not relevant to the scenario of making assignments.

Choice D is wrong because Fidelity is wrong because fidelity is the ethical principle of keeping promises to the patient.

This principle is not relevant to the scenario of making assignments.

A. Leg cramps. B. Ptyalism. C. Blurred vision. D. Melasma.

Correct Answer is C

Explanation

This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.

The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.

Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.

Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.

Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.

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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?

Nursing Test Bank

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Correct Answer is C

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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?