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:
A client exhibiting psychotic behavior may not be the best candidate for group therapy initially, as they might be experiencing delusions, hallucinations, or disorganized thinking that could disrupt the group process and might not be able to participate effectively. Individual therapy might be more appropriate until the client's symptoms are better managed.
Choice B Reason:
A client who was admitted 5 hours ago for acute mania is likely still experiencing heightened levels of energy, impulsivity, and possibly erratic behavior. They may not be able to engage in group therapy effectively and could benefit from stabilization before participating in a group setting.
Choice C Reason:
A client who has been taking lithium for 2 weeks for depression is likely to have achieved some level of stabilization of their mood. Lithium is a mood stabilizer used to treat bipolar disorder and depression, and after 2 weeks, the client may be ready to engage with others in a therapeutic group setting.
Choice D Reason:
A client who is in a manic state, similar to the client in choice B, may not be suitable for group therapy due to potential disruptive behavior and difficulty focusing on the group process. It's important for the client to receive individual attention to manage the mania before joining group therapy.
Question 43
Correct Answer is C
Explanation
Choice A reason - "Don't worry. We'll take good care of your parent while you are gone.":
This statement is meant to reassure the son that his parent will be well-cared for in his absence, which is an important concern for family members of patients. However, it does not provide any immediate comfort or solution to his dilemma of needing to be in two places at once.
Choice B reason - "You are feeling drawn in two separate directions.":
By acknowledging the son's feelings, the nurse is showing understanding and empathy. Recognizing the emotional conflict is a key step in providing emotional support, but the response stops short of offering actionable advice or comfort.
Choice C reason - "Perhaps you could call your children to see how they are doing.":
This suggestion is helpful because it gives the son a way to be involved with his children's well-being without having to leave the hospital. It's a compromise that addresses both of his concerns and can provide him with some peace of mind.
Choice D reason - "There's nothing you can do here. You should go home to your children.":
While this might be a practical suggestion, it fails to consider the son's emotional state and his need to support his hospitalized parent. It could make him feel guilty or negligent for considering leaving, even if it's to attend to his children.
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