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. Place a heated fan at the bedside to facilitate drying: Using a heated fan can increase the risk of burns to the child's skin underneath the cast. The drying process for a cast should occur naturally, and artificial heat sources should not be used.

B. Support the casted arm with a firm grasp: While it's important to support the child's arm during the casting procedure, doing so with a firm grasp may not be necessary or appropriate. The nurse should follow the orthopedic surgeon's instructions regarding the positioning and support of the arm during casting.

C. Tell the child, "This will make your arm feel better": This statement may not accurately reflect the purpose of the cast, as casting is typically done to immobilize and protect the injured limb during the healing process. It's important to provide developmentally appropriate explanations to children about medical procedures, but this particular statement may not be helpful or accurate in this context.

D. Wrap the arm of the child's doll or toy prior to the procedure: This action helps familiarize the child with the procedure and can serve as a form of therapeutic play. By involving the child's toy or doll, the nurse can help reduce anxiety and fear associated with the casting procedure. It also provides an opportunity for the child to understand what will happen to their own arm, promoting a sense of familiarity and control over the situation.

A. The client drinks 2 liters of liquids daily. B. The client runs 4 miles outdoors every afternoon. C. The client eats 2 to 3 gm of sodium-containing foods daily D. The client eats foods high in tyramine

Correct Answer is B

Explanation

A. The client drinks 2 liters of liquids daily: Adequate hydration is important when taking lithium to prevent dehydration, which can increase lithium levels. Drinking 2 liters of liquids daily is appropriate and helps maintain hydration, reducing the risk of lithium toxicity.

B. The client runs 4 miles outdoors every afternoon: Vigorous exercise and excessive sweating, such as running 4 miles outdoors daily, can lead to dehydration and increased lithium levels, thereby increasing the risk of lithium toxicity. Clients taking lithium should be advised to avoid excessive sweating and to maintain adequate hydration during exercise.

C. The client eats 2 to 3 gm of sodium-containing foods daily: Consuming sodium-containing foods helps prevent lithium toxicity by promoting lithium excretion through the kidneys. Adequate sodium intake is necessary to maintain lithium balance in the body. Eating 2 to 3 grams of sodium-containing foods daily is within the recommended range for clients taking lithium.

D. The client eats foods high in tyramine: Foods high in tyramine are associated with the risk of hypertensive crisis, particularly in clients taking monoamine oxidase inhibitors (MAOIs), not lithium. While dietary restrictions may be necessary for clients taking MAOIs, they are not relevant to lithium therapy.

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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?

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