A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

Implementation

Evaluation

Assessment

Planning

Answer and Explanation

The Correct Answer is C

Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.

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Correct Answer is B

Explanation

Choice A reason:
The 24-year-old only being the client would imply that the therapy session is focused solely on the individual issues of the 24-year-old. However, the context of the therapy session, which includes multiple family members, suggests that the focus is on addressing family dynamics and conflicts. Family therapy typically involves working with the entire family unit to improve relationships and resolve conflicts, rather than focusing on a single individual.

Choice B reason:
The entire family being the client is the correct answer because family therapy aims to address issues within the family system as a whole. By involving the 24-year-old, his sister, his mother, and the mother’s live-in boyfriend, the therapy session is designed to explore and resolve conflicts that affect the entire family. This approach recognizes that individual issues are often interconnected with family dynamics, and addressing these dynamics can lead to more effective and lasting solutions.

Choice C reason:
The 24-year-old and his mother being the clients would limit the scope of the therapy to the relationship between these two individuals. While this might address some aspects of the family conflict, it would not provide a comprehensive approach to resolving issues that involve other family members, such as the sister and the mother’s live-in boyfriend. Family therapy is most effective when all relevant members are included in the process.

Choice D reason:
The sister, mother, and 24-year-old being the clients would exclude the mother’s live-in boyfriend, who is also part of the family dynamic. Excluding any family member who is involved in the conflict can limit the effectiveness of the therapy. Family therapy aims to include all relevant members to fully understand and address the issues affecting the family as a whole. Therefore, this option is not as comprehensive as involving the entire family.

A. Assign an assistive personnel to feed the client at mealtimes. B. Use touch to calm the client during periods of anxiety. C. Rotate staff assignments for this client. D. Check the client’s mouth after the client takes medication.

Correct Answer is D

Explanation

Choice A reason:
Assigning assistive personnel to feed the client at mealtimes is not typically necessary for clients with paranoid schizophrenia unless there are specific physical limitations. This intervention does not address the unique needs of managing paranoia and ensuring medication adherence.

Choice B reason:
Using touch to calm the client during periods of anxiety is not recommended for clients with paranoid schizophrenia. These clients may misinterpret touch as a threat, exacerbating their paranoia and anxiety.

Choice C reason:
Rotating staff assignments for this client can increase anxiety and paranoia. Consistency in caregivers helps build trust and reduces the client’s suspicion and anxiety.

Choice D reason:
Checking the client’s mouth after the client takes medication is crucial to ensure that the client has swallowed the medication. Clients with paranoid schizophrenia may hide or refuse medication due to their distrust, so this intervention helps ensure they receive their prescribed treatment.

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A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After experiencing increasing conflict in the home, a social worker calls and schedules a therapy meeting. A 24-year-old, his sister, his mother, and the mother’s live-in boyfriend are asked to attend the therapy meeting. Who is the “client” who will be treated during this session?

Correct Answer is B

Explanation

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Correct Answer is D

Explanation

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