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 D

Explanation

A. "You must be getting better. You look great!": This response could potentially be interpreted as positive reinforcement, but it carries the risk of making assumptions about the client's mental state solely based on their appearance. It implies that the client's improved grooming is solely due to their improvement in depression, which may not necessarily be the case. Additionally, it may inadvertently minimize the client's experience of depression by attributing their grooming to improvement rather than recognizing it as an achievement in itself.

B. "Everyone feels better after showering": This response generalizes the client's experience and minimizes the significance of their actions. It implies that grooming is merely a routine activity that everyone does and that feeling better is solely related to physical cleanliness. It fails to acknowledge the client's effort and positive behavior, which could be significant achievements for someone experiencing depression.

C. "Why are you all dressed up today? Is it a special occasion?": This response might put the client on the spot and make them feel uncomfortable or self-conscious about their appearance. It could also imply that there must be a specific reason for the client to take care of their grooming, rather than recognizing it as a positive step regardless of the reason. Additionally, it doesn't acknowledge the client's effort or provide validation for their behavior.

D. "I see you have done some grooming today.": This response acknowledges the client's effort and positive behavior without making assumptions or judgments about the client's mental state or improvement. It demonstrates observance and recognition of the client's actions, which can help build rapport and trust between the nurse and the client. Additionally, it opens the door for further conversation if the client wishes to discuss their grooming habits or how they are feeling.

A. Rickets B. Iron deficiency anemia C. Obesity D. Diabetes mellitus

Correct Answer is B

Explanation

A. Rickets: Rickets is a condition caused by a deficiency of vitamin D, calcium, or phosphate, leading to softening and weakening of the bones. While milk is a good source of vitamin D and calcium, excessive consumption of milk alone may not necessarily lead to rickets unless the child has inadequate exposure to sunlight or a diet lacking in other essential nutrients.

B. Iron deficiency anemia: This is the correct choice. Excessive consumption of milk, particularly if it replaces solid foods in the diet, can lead to iron deficiency anemia in toddlers. Cow's milk is low in iron and can inhibit iron absorption from other foods, leading to iron deficiency over time. Iron deficiency anemia can result in fatigue, weakness, developmental delays, and impaired cognitive function in young children.

C. Obesity: While excessive milk consumption can contribute to excessive calorie intake, leading to weight gain and potentially obesity, the scenario describes a toddler with a poor appetite for solid foods. Therefore, the primary concern in this case is not obesity but rather the risk of nutritional deficiencies, particularly iron deficiency anemia.

D. Diabetes mellitus: Excessive milk consumption alone is not a direct risk factor for diabetes mellitus in toddlers. However, a diet high in refined sugars and excessive calorie intake, including from milk, can contribute to the development of obesity and insulin resistance, increasing the risk of type 2 diabetes mellitus later in life. However, the primary concern in this scenario is the risk of nutritional deficiencies, particularly iron deficiency anemia, rather than diabetes mellitus.

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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?

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