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 C

Explanation

A. "You are being unreasonable, and I will not call your doctor at this hour."

This response may escalate the situation by invalidating the client's feelings and refusing to address their request. It fails to recognize the client's distress and could lead to increased agitation or frustration.

B. "I can't call a doctor in the middle of the night unless it's an emergency."

While it's true that non-urgent matters may be deferred until regular hours, this response comes across as dismissive and may exacerbate the client's distress. It does not validate the client's feelings or offer support.

C. "You must be very upset about something."

This response acknowledges the client's emotions and shows empathy. It opens the door for the client to express their concerns, allowing the nurse to assess the situation further and address any immediate needs. It also avoids dismissing the client's request outright and maintains a therapeutic relationship.

D. "Go back to your room, and I'll try to get in touch with your doctor."

This response instructs the client to return to their room without addressing their emotional state or concerns. It lacks empathy and fails to engage with the client's needs effectively.

A. "You have a great deal to live for." B. "It's not unusual for depressed people to feel that way." C. "You've been feeling that your life has no meaning." D. "Why do you feel you are worthless?"

Correct Answer is C

Explanation

A. "You have a great deal to live for."

While this response is supportive and positive, it may not effectively address the client's feelings of worthlessness. It may come across as dismissive or invalidating of the client's emotions.

B. "It's not unusual for depressed people to feel that way."

This response acknowledges the commonality of feeling worthless among individuals with depression. While it normalizes the client's experience, it doesn't directly address the client's statement or offer support.

C. "You've been feeling that your life has no meaning."

This response reflects active listening and demonstrates empathy by paraphrasing the client's statement to show understanding. It acknowledges the client's feelings and opens the door for further exploration of the underlying issues contributing to their sense of worthlessness.

D. "Why do you feel you are worthless?"

While this response seeks to explore the underlying reasons for the client's feelings, it may come across as confrontational or judgmental. It puts the client on the spot to justify their emotions, which could make them feel defensive or invalidated.

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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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