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 C
Explanation
Choice A reason:
While a mental health unit that includes milieu therapy may focus on stabilizing clients, it is not limited to those in an acute phase of mental illness. Milieu therapy is a comprehensive approach that can benefit individuals at various stages of their treatment.
Choice B reason:
Milieu therapy is not necessarily less intensive nor does it focus solely on one psychiatric illness or substance abuse disorder. It is a versatile treatment method that can be applied to a range of conditions and is integrated into the daily life of the unit.
Choice C reason:
This choice accurately reflects the essence of milieu therapy. It is a therapeutic approach where the environment is used as an integral part of treatment. The goal is to create a stable, adaptive reality through routines, boundaries, and open communication, fostering a sense of safety and support for therapeutic change.
Choice D reason:
Milieu therapy is not exclusively focused on long-term care but is adaptable to the needs of clients, whether they require short-term stabilization or long-term treatment. It is designed to help individuals learn healthier ways of thinking and behaving within a supportive community setting.
Correct Answer is B
Explanation
Choice A Reason: While this response may seem compassionate, it does not encourage the client to engage in activities that could benefit their mental health. Allowing the client to remain isolated may reinforce feelings of helplessness or depression. It is important to motivate clients to participate in therapeutic activities to promote their recovery.
Choice B Reason: This response is supportive and offers a compromise. It acknowledges the client’s current state and provides assistance, while also gently encouraging participation in activities. By offering help and allowing for rest afterward, the nurse is using an empathetic approach to facilitate the client’s involvement in the unit’s programs.
Choice C Reason: This response is coercive and could be considered a threat. It is not therapeutic to withhold basic needs such as meals as a form of punishment or to force compliance. Such an approach can damage the nurse-client relationship and is not conducive to the client’s recovery.
Choice D Reason: This response may come across as dismissive and demanding. It does not offer support or acknowledge the client’s feelings. Telling the client what they “need” to do without offering help or understanding can lead to resistance and a lack of trust in the nurse-client relationship.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.