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 ["A","C"]
Explanation
Choice A reason:
The Bradley method teaches the labor partner how to coach and support the mother during labor. This is true because the Bradley method emphasizes the role of the partner as an active participant and a skilled coach who can help the mother relax, breathe, and cope with pain during labor. The partner also serves as an advocate for the mother's preferences and needs in the hospital setting.
Choice B reason:
The Bradley method teaches the mother and partner about the variety of methods to control pain. This is false because the Bradley method does not teach a variety of methods to control pain, but rather focuses on relaxation as the main way to reduce pain during labor. The Bradley method also discourages the use of medication or medical interventions for pain relief, unless they are medically necessary.
Choice C reason:
The Bradley method prepares the woman to deliver without medical interventions and medications. This is true because the Bradley method aims to help women have an unmedicated birth with minimal medical intervention. The Bradley method teaches women how to avoid unnecessary interventions and how to cope with natural labor by using relaxation, breathing, nutrition, and exercise. The Bradley method also educates women on how to reduce their risk of having a C-section and what to do if it becomes medically necessary.
Choice D reason:
The Bradley method focuses on muscle control because muscle tension increases the pain of labor. This is false because the Bradley method does not focus on muscle control, but rather on deep and complete relaxation during labor. The Bradley method believes that muscle tension interferes with the natural process of labor and increases pain, so it teaches women how to relax their muscles and let their bodies do the work.
Choice E reason:
The Bradley method is the most widely used method in the US. This is false because the Bradley method is not the most widely used method in the US, but rather one of several options for natural childbirth. According to a 2017 survey by Listening to Mothers, only 4% of women reported using the Bradley method for their most recent birth, compared to 48% who used Lamaze, 14% who used hypnobirthing, and 9% who used other methods.
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.
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