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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Place the infant in an infant seat for 2 hours following the procedure. There is no specific need to place the infant in an infant seat for 2 hours following a lumbar puncture. After the procedure, the infant should be positioned comfortably and safely, but there is no requirement for a specific duration in an infant seat.

B. Hold the infant's chin to his chest and knees to his abdomen during the procedure. This positioning is not appropriate for a lumbar puncture. The correct positioning for a lumbar puncture involves having the infant in a lateral recumbent (side-lying) position with knees flexed up toward the chest, allowing the spine to be flexed and creating space between the vertebrae for the needle insertion.

C. Keep the infant NPO for 6 hours prior to the procedure. Keeping the infant NPO (nothing by mouth) for 6 hours prior to the procedure is not necessary for a lumbar puncture. Infants can continue breastfeeding or formula feeding as usual before the procedure. However, if sedation or anesthesia is planned for the procedure, specific fasting guidelines may apply depending on institutional protocols and the infant's age and health status.

D. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 minutes prior to the procedure. This is the correct choice. Applying a eutectic mixture of lidocaine and prilocaine cream topically before the procedure helps to numb the skin and reduce pain at the site of the lumbar puncture. It is a standard practice to minimize discomfort for the infant during the procedure.

A. Providing support for family and friends following a suicide B. Recognizing the warning signs of suicide C. Performing life-saving measures following a suicide attempt D. Identifying individuals who are at higher risk for attempting suicide

Correct Answer is C

Explanation

A. Providing support for family and friends following a suicide:

Providing support for family and friends following a suicide is an example of a tertiary intervention. Tertiary interventions focus on providing support, counseling, and resources to individuals affected by suicide after the event has occurred, aiming to prevent further emotional distress, promote healing, and reduce the risk of additional suicides in the community.

B. Recognizing the warning signs of suicide:

Recognizing the warning signs of suicide is an example of a primary intervention. Primary interventions aim to prevent suicide by identifying individuals at risk and intervening before a suicide attempt occurs. Educating healthcare professionals and the community about the warning signs of suicide is crucial for early identification and intervention.

C. Performing life-saving measures following a suicide attempt:

This is an example of a secondary intervention. Secondary interventions involve actions taken after the occurrence of a suicide attempt or completed suicide to prevent further harm or loss of life. Performing life-saving measures, such as cardiopulmonary resuscitation (CPR) or providing emergency medical care, falls under secondary interventions because it occurs after the suicide attempt to mitigate the immediate physical consequences.

D. Identifying individuals who are at higher risk for attempting suicide:

Identifying individuals who are at higher risk for attempting suicide is also an example of a primary intervention. This involves screening, assessment, and risk evaluation to identify individuals with risk factors and warning signs of suicide, allowing for targeted interventions, support, and prevention strategies to be implemented before a suicide attempt occurs.

View Question and Answer

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

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

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture. Which one of the following should the nurse include in the plan of care?

Correct Answer is D

Explanation

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary Intervention?

Correct Answer is C

Explanation

A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take?

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

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?

A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?