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. Imaginary playmates:

Toddlers typically do not engage in activities involving imaginary playmates. This behavior is more common in preschool-aged children.

B. Erikson's stage of initiative versus guilt:

Erikson's stage of initiative versus guilt occurs during the preschool years, typically around ages 3 to 5. It involves children developing a sense of initiative to take on new tasks and challenges, balanced with feelings of guilt if they are overly criticized or restricted.

C. Negative behaviors characterized by the need for autonomy:

This is the correct answer. Toddlers are in Erikson's stage of autonomy versus shame and doubt. During this stage, which typically occurs between the ages of 1 and 3, toddlers strive to gain independence and autonomy. They may exhibit negative behaviors, such as temper tantrums or defiance, as they assert their independence and explore their environment.

D. Demonstrations of sexual curiosity:

Demonstrations of sexual curiosity typically emerge later in childhood, around the preschool years or later. Toddlers are not typically focused on sexual curiosity during this stage of development.

A. Before auscultating the chest and abdomen B. Before examining the head and neck C. At the end D. At the beginning

Correct Answer is C

Explanation

A. Before auscultating the chest and abdomen: Examining the tympanic membrane before auscultating the chest and abdomen is not ideal. It's important to follow a systematic approach in physical examination, typically starting with less invasive assessments before progressing to more invasive or uncomfortable ones. Therefore, examining the tympanic membrane before auscultating the chest and abdomen may disrupt this systematic approach.

B. Before examining the head and neck: Similarly, examining the tympanic membrane before examining the head and neck is not appropriate. The head and neck examination typically includes less invasive assessments such as observing the child's appearance, palpating the fontanelles, and inspecting the scalp, face, and neck. The tympanic membrane examination, which involves using an otoscope, is more invasive and should be performed later in the examination.

C. At the end: This is the correct choice. Examining the tympanic membrane at the end of the physical examination allows the nurse to establish rapport with the child and gain their cooperation before performing a potentially uncomfortable or intrusive examination of the ears. Starting with less invasive and more familiar assessments, such as observing the child's general appearance and behavior, auscultating the chest and abdomen, and examining the head and neck, can help build trust and reduce anxiety before proceeding to more specific assessments, such as otoscopy.

D. At the beginning: Examining the tympanic membrane at the beginning of the physical examination may cause the child distress and anxiety, potentially making the rest of the examination more challenging. It's preferable to perform less invasive assessments first to help the child become more comfortable and cooperative before proceeding to more invasive examinations like otoscopy. Therefore, examining the tympanic membrane at the beginning is not recommended.

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