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 A

Explanation

A. Assist the client to the correct room: This option addresses the immediate safety concern by guiding the client back to their own room, reducing distress for both the client and the other resident. It promotes dignity and minimizes the risk of agitation or further disruptive behavior.

B. Place the client in restraints: Restraints should only be used as a last resort for safety when all other measures have been exhausted and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful to individuals with Alzheimer's disease and should not be used unless absolutely necessary.

C. Reorient the client to time and place: Reorientation may not be effective for clients with advanced Alzheimer's disease, as their cognitive impairments may limit their ability to understand or retain this information. Additionally, reorientation may not address the immediate safety concern posed by the client's behavior.

D. Move the client to a room at the end of the hall: While this option may be considered in some situations to minimize disruption to other residents, it does not address the underlying issue of the client's confusion or wandering behavior. Additionally, moving the client may cause further distress and confusion.

A. Expressive affect B. Ambivalence C. Echolalia D. Associative looseness

Correct Answer is C

Explanation

A. Expressive affect: Individuals with autism spectrum disorder (ASD) often have difficulty expressing their emotions in a typical manner. They may display a restricted range of facial expressions or have difficulty conveying emotions through facial expressions and gestures. However, "expressive affect" typically refers to the appropriate display of emotions, which may not be characteristic of ASD.

B. Ambivalence: Ambivalence refers to conflicting feelings or attitudes about a situation or person. While individuals with ASD may experience a range of emotions, including ambivalence, it is not a specific characteristic associated with the disorder. Ambivalence is a common human experience and may occur in individuals with or without ASD.

C. Echolalia: Echolalia is a common communication characteristic observed in individuals with ASD. It involves the repetition or echoing of words or phrases spoken by others. This behavior may occur immediately after hearing the words or phrases (immediate echolalia) or may be delayed. Echolalia can serve various functions, including communication, self-regulation, or expression of anxiety.

D. Associative looseness: Associative looseness is a thought disorder characterized by a lack of logical connection between thoughts and ideas. It is typically associated with conditions such as schizophrenia rather than ASD. Individuals with ASD may exhibit difficulties with social communication, including challenges in maintaining conversations or understanding social cues, but this is different from the disorganized thinking observed in associative looseness.

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 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?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply).

A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply.)

A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler?

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

A nurse on a mental health unit is caring for clients who have various d Bryant traction. When determining that the traction is the following client diagnoses as presenting the greatest risk for suicide?

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane??