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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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