A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?
Directly tell the client that the delusions are not real.
Use frequent touch to provide client support.
Place the client in seclusion if visual hallucinations are present.
Limit the number of questions asked during assessments.
The Correct Answer is D
Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.
Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.
Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.
Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Offering false reassurance occurs when a nurse or healthcare provider dismisses a patient's concerns with general comforting statements without addressing the reality of the situation or the patient's feelings. In this case, the nurse's response of "Don't worry, no one will harm your family" is an attempt to alleviate the patient's anxiety without acknowledging the patient's fear or providing a realistic plan to ensure the safety of the patient's family. This type of communication can undermine trust and prevent the patient from feeling heard and supported.
Choice B Reason:
Offering sympathy involves sharing feelings of pity or sorrow for someone else's misfortune. While the nurse's response may seem sympathetic, it does not directly express shared emotions or an understanding of the patient's distress. Therefore, it does not represent offering sympathy as a communication breakdown in this context.
Choice C Reason:
Providing a passive response would involve the nurse not actively engaging with the patient's concerns or failing to provide any response. Since the nurse in the scenario does respond to the patient's statement, this does not constitute a passive response.
Choice D Reason:
Showing disapproval would involve the nurse expressing judgment or criticism of the patient's feelings or actions. The nurse's response does not contain elements of judgment or criticism; rather, it is an attempt to reassure the patient, albeit falsely.
Correct Answer is D
Explanation
Choice A reason:
Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.
Choice B reason:
Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.
Choice C reason:
Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.
Choice D reason:
Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.
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