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. "Try switching to a different formula." While switching formula might be an option if the infant is having feeding issues, projectile vomiting in a 2-month-old infant could indicate a more serious condition, such as pyloric stenosis. It's essential for the nurse to assess the infant's condition in person rather than recommending a formula change over the phone.

B. "Burp your baby more frequently during feedings." Burping the baby more frequently might help reduce gas but is unlikely to resolve projectile vomiting, which can be a sign of a medical issue requiring prompt attention.

C. "Bring your baby in to the clinic today." This response is the most appropriate because projectile vomiting in an infant, especially when combined with increased hunger, could indicate a serious condition like pyloric stenosis or other gastrointestinal problems. The infant needs to be assessed by a healthcare provider as soon as possible to determine the cause and initiate appropriate treatment.

D. "Give your infant an oral rehydration solution." Oral rehydration solutions are typically used to replenish fluids lost due to vomiting or diarrhea. However, in this case, the priority is to determine the cause of the projectile vomiting, which requires a thorough assessment by a healthcare provider.

A. Increased urinary output B. Anorexia C. Jaundice D. Diarrhea

Correct Answer is B

Explanation

A. Increased urinary output: Acute lead poisoning typically does not lead to increased urinary output. Instead, lead toxicity can affect renal function, potentially leading to kidney damage and decreased urinary output or even renal failure in severe cases.

B. Anorexia: Acute lead poisoning can lead to gastrointestinal symptoms such as abdominal pain, nausea, and vomiting, which can result in decreased appetite or anorexia. Lead poisoning affects multiple organ systems, including the gastrointestinal tract, leading to symptoms like abdominal pain and gastrointestinal upset. Anorexia is a common manifestation in individuals, including toddlers, with acute lead poisoning due to these gastrointestinal symptoms.

C. Jaundice: Jaundice is not a typical finding in acute lead poisoning. Jaundice typically occurs when there is an accumulation of bilirubin in the blood, which can be caused by liver dysfunction or obstruction of the bile ducts. Lead poisoning primarily affects the central nervous system, hematopoietic system, and gastrointestinal system rather than the liver.

D. Diarrhea: While gastrointestinal symptoms such as abdominal pain, nausea, and vomiting can occur in acute lead poisoning, diarrhea is not a characteristic symptom. Lead poisoning can cause constipation rather than diarrhea due to its effects on the gastrointestinal tract, such as slowing peristalsis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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