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 D

Explanation

A. Suppression: Suppression involves consciously pushing down or ignoring thoughts, feelings, or memories that are perceived as unacceptable or distressing. In this scenario, the client is not consciously trying to push down or ignore their behavior; instead, they are explaining their actions using a defense mechanism.

B. Reaction-formation: Reaction-formation occurs when an individual expresses feelings or behaviors that are the opposite of their true feelings or desires. In this case, the client's statement does not involve expressing the opposite of their true feelings. Instead, they are rationalizing their behavior.

C. Compensation: Compensation involves attempting to overcome feelings of inadequacy or failure in one area by excelling in another area. The client's statement does not suggest that they are compensating for anything; rather, they are explaining their behavior through a defense mechanism.

D. Rationalization: Rationalization involves providing logical or socially acceptable reasons for behavior that are not the true reasons. In this scenario, the client is rationalizing their behavior by attributing it to external factors, such as their boss's influence, rather than acknowledging their own responsibility for their actions. This defense mechanism allows the client to avoid facing the underlying issue of alcohol abuse by providing a seemingly reasonable explanation for their behavior.

A. "You should get a psychological consult for the temper tantrums." B. "You should leave the room while the tantrum is happening." C. "Temper tantrums are a type of learning disability." D. "Temper tantrums are the toddler's attempt to gain control of a situation."

Correct Answer is D

Explanation

A. "You should get a psychological consult for the temper tantrums." This statement may cause unnecessary concern for the parents. Temper tantrums are a common behavior in toddlers and typically do not require a psychological consult unless they are severe, persistent, or accompanied by other concerning behaviors.

B. "You should leave the room while the tantrum is happening." Leaving the room while the tantrum is occurring may not be the most effective approach. It's important for parents to provide comfort and support to their toddler during a tantrum, while also setting appropriate limits and boundaries.

C. "Temper tantrums are a type of learning disability." Temper tantrums are not indicative of a learning disability. They are a normal part of development and occur as toddlers learn to express their emotions and navigate their environment.

D. "Temper tantrums are the toddler's attempt to gain control of a situation." This statement is accurate. Temper tantrums often occur when toddlers feel frustrated, overwhelmed, or unable to express their needs effectively. Tantrums are a way for toddlers to assert their independence and gain control over their environment. Understanding this can help parents respond to tantrums with patience and empathy, while also setting appropriate limits and teaching coping strategies.

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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 D

Explanation

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Correct Answer is D

Explanation

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