A nurse is developing a plan of care 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?

Use frequent touch to provide client support.

Directly tell the client that delusions are not real

Limit the number of questions asked during assessments

Place the client in seclusion visual hallucinations are present

Answer and Explanation

The Correct Answer is C

A. Using frequent touch to provide client support: While touch can be comforting for some clients, individuals with schizophrenia, especially those experiencing paranoid delusions, may interpret touch as threatening or intrusive. Therefore, using frequent touch may exacerbate the client's paranoia and increase their distress.

B. Directly telling the client that delusions are not real: Directly challenging the client's delusions may cause them to become defensive or agitated. It is unlikely to be effective in changing the client's beliefs and may damage the therapeutic relationship. Instead, the nurse should use therapeutic communication techniques to explore the client's perceptions and validate their feelings while gently offering alternative perspectives.

C. Limiting the number of questions asked during assessments: Individuals experiencing frequent hallucinations and paranoid delusions may have difficulty concentrating and processing information. Limiting the number of questions asked during assessments reduces cognitive overload and helps prevent overwhelming the client. The nurse should prioritize asking clear, concise questions relevant to the client's immediate needs.

D. Placing the client in seclusion if visual hallucinations are present: Seclusion should only be used as a last resort and when absolutely necessary to ensure the safety of the client or others. It is not an appropriate intervention for managing hallucinations alone. Instead, the nurse should employ therapeutic communication techniques, provide a safe and supportive environment, and use prescribed medications as indicated to manage the client's symptoms.

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Correct Answer is B

Explanation

A. A story book about a child who has diabetes. While providing information about diabetes through a storybook may be beneficial for the child's understanding of the condition, it may not directly address the distress experienced after an insulin injection. This option focuses more on education rather than immediate coping with the injection-related distress.

B. A needleless syringe and a doll. This is the correct choice. Providing a needleless syringe and a doll allows the child to engage in pretend play and role-play scenarios related to the insulin injection experience. Through play, the child can express their feelings, fears, and experiences in a safe and non-threatening environment. This type of play activity can help the child gain a sense of control, familiarity, and mastery over the situation, thereby reducing distress and anxiety associated with future injections.

C. A period of play in the playroom. While engaging in play in the playroom may offer the child opportunities for distraction and enjoyment, it may not specifically address the distress experienced after an insulin injection. The effectiveness of this option in helping the child cope with the injection-related distress may depend on the specific activities available in the playroom and the child's preferences.

D. A video game. Playing a video game may provide the child with distraction and entertainment, but it may not directly address the distress experienced after an insulin injection. Additionally, screen time may not be suitable for every child, and the therapeutic benefits of video games in this context may vary.

A. Provide a small electronic toy B. Change the infant's diaper as soon as soiling occurs. C. Allow the infant to stand in the crib D. The colorful latex balloons to the side of the crib

Correct Answer is A

Explanation

A. Provide a small electronic toy.

Providing a small electronic toy can engage the infant's senses and promote cognitive development. Interactive toys can stimulate the infant's curiosity, encourage exploration, and provide sensory stimulation, which are important aspects of infant development. However, the selection of toys should consider safety and age appropriateness, ensuring they do not pose a choking hazard or contain small parts that the infant could ingest.

B. Change the infant's diaper as soon as soiling occurs.

Changing the infant's diaper promptly when soiling occurs is essential for maintaining hygiene and preventing skin irritation or infection. However, while diaper changes are necessary for the infant's comfort and well-being, they primarily address basic needs rather than directly promoting growth and development related to the hip dysplasia.

C. Allow the infant to stand in the crib.

Allowing the infant to stand in the crib may not be suitable, especially if the infant is in a cast for developmental dysplasia of the hip (DDH). The cast is typically intended to maintain the hip joint in a specific position to promote proper alignment and development. Allowing the infant to stand in the crib could compromise the effectiveness of the treatment and potentially exacerbate the hip dysplasia. Therefore, this option is not appropriate.

D. Tie colorful latex balloons to the side of the crib.

Tying colorful latex balloons to the side of the crib is not recommended due to safety concerns. Latex balloons pose a choking hazard if they deflate or rupture, and the infant could accidentally ingest the latex material, leading to airway obstruction or other complications. Safety is paramount in infant care, and any potential hazards should be avoided.

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A nurse is developing a plan of care 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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