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:
The statement correctly identifies that a therapeutic milieu encompasses both the physical and psychosocial aspects of the environment. This holistic approach is designed to support the recovery and well-being of clients by ensuring that all aspects of the unit's environment are conducive to therapy.
Choice B reason:
While personalization of space can be part of a therapeutic milieu, this statement alone does not capture the full essence of the concept. Therapeutic milieu involves more than just personal items; it includes the structured management of the environment to promote positive interactions and therapeutic outcomes.
Choice C reason:
Positioning chairs around the perimeter of the day room may be a part of the environmental setup, but it does not fully represent the therapeutic milieu. The therapeutic milieu is about creating an environment that encourages interaction, communication, and community among clients, which may or may not involve specific furniture arrangements.
Choice D reason:
Unstructured programming is not a characteristic of therapeutic milieu. In fact, therapeutic milieu typically involves a structured schedule of activities and programs that are designed to promote therapeutic engagement, skill development, and social interaction among clients.
Correct Answer is A
Explanation
Choice A Reason:
Providing continuity of care by assigning the same staff is essential in creating a therapeutic environment. It allows for the development of trust and rapport, which are foundational for effective mental health treatment. Consistent caregivers can better understand the clients' needs and tailor interventions accordingly.
Choice B Reason:
While it is important to be open to discussing various topics, the nurse must ensure that discussions remain therapeutic and relevant to treatment goals. Some topics may need to be redirected or limited to maintain a safe and supportive environment.
Choice C Reason:
Allowing clients to determine the boundaries of the nurse-client relationship could lead to blurred lines that may affect the quality of care. It is the nurse's responsibility to establish clear professional boundaries while being empathetic and supportive.
Choice D Reason:
Focusing on client wellness is a broad concept that encompasses the clients' physical, mental, and social well-being. It is a goal of the therapeutic environment to promote overall wellness, but specific strategies are needed to achieve this aim.
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