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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Free Nursing Study Resources

Correct Answer is A

Explanation

Lithium toxicity is a significant concern for clients taking lithium, a mood stabilizer commonly prescribed for bipolar disorder. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood, potentially leading to toxicity. Therefore, cautioning against experiencing diarrhea is essential in discharge teaching for clients prescribed lithium.

Option A is correct because it identifies a factor that can contribute to lithium toxicity. Diarrhea can lead to fluid and electrolyte imbalances, affecting lithium levels in the blood.

Option B, drinking green tea, is not typically associated with lithium toxicity. Green tea contains caffeine, but its consumption is not a significant risk factor for lithium toxicity.

Option C, exercising moderately, is generally encouraged for overall health and well-being. However, it does not directly relate to lithium toxicity unless excessive sweating leads to dehydration and electrolyte imbalances.

Option D, increasing sodium intake, is typically discouraged for clients taking lithium because high sodium levels can affect lithium reabsorption in the kidneys, potentially leading to increased lithium levels and toxicity. However, this option is not directly related to the question about factors causing lithium toxicity.

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

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Correct Answer is A

Explanation

A nurse is assessing a toddler who has suspected lead poisoning. Which of the following findings should the nurse expect the client to manifest with acute lead poisoning?

Correct Answer is B

Explanation

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