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 nurse's response is therapeutic because it clearly communicates the expectations of the treatment setting in a firm yet non-confrontational manner. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing structure and clarity, which can help orient the client to the reality of the situation and the routine of the therapeutic environment.
Choice B reason:
While the nurse's response does include a statement of understanding, it does not primarily demonstrate empathy. Empathy would involve acknowledging the client's feelings and concerns more directly, rather than focusing on the expectations of the therapy session.
Choice C reason:
Reflection is a therapeutic communication technique where the nurse repeats or paraphrases what the client has said to show that they are listening and to encourage further discussion. In this case, the nurse does not use reflection but rather responds with a statement of expectation.
Choice D reason:
The nurse's response does not set limits on manipulative behavior, as there is no indication that the client's behavior is manipulative. The client expresses a delusional belief, and the nurse addresses this by redirecting the client to the scheduled group therapy session.
Correct Answer is D
Explanation
Choice A reason:
Acute dystonia is characterized by sudden muscle contractions that can cause abnormal postures. While it is an adverse effect of antipsychotic medications, the symptoms typically include muscle spasms, stiffness, and oculogyric crisis, but not necessarily fever and diaphoresis.
Choice B reason:
Tardive dyskinesia is a late-onset movement disorder associated with prolonged use of antipsychotic medications. It presents with repetitive, involuntary, and purposeless movements, such as grimacing, tongue movements, and lip smacking. Fever and blood pressure changes are not typical features of tardive dyskinesia.
Choice C reason:
Pseudoparkinsonism is an adverse effect of antipsychotic medications that mimics the symptoms of Parkinson's disease, such as tremor, rigidity, bradykinesia, and postural instability. However, it does not usually present with fever or diaphoresis.
Choice D reason:
Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic emergency associated with the use of antipsychotic medications. It is characterized by mental status changes, muscle rigidity, fever, and autonomic dysfunction, such as blood pressure changes and diaphoresis. NMS requires immediate medical attention and discontinuation of the offending agent.
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