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?
Use touch to calm the client during periods of anxiety
Check the clients mouth after the client takes medication
Rotate the staff assignments for this client
Assign an assistive personnel to feed the client at meat times
The Correct Answer is B
A. Use touch to calm the client during periods of anxiety:
Individuals with paranoid schizophrenia may have heightened sensitivity to touch, and it can potentially exacerbate their anxiety or paranoia. This intervention may not be appropriate as it could escalate the client's distress.
B. Check the client's mouth after the client takes medication:
This is the best choice. People with paranoid schizophrenia may be prone to hoarding or pocketing medications. Checking the client's mouth ensures that the medication has been swallowed, promoting medication adherence and preventing potential harm.
C. Rotate the staff assignments for this client:
Consistency in caregivers is generally preferred for clients with schizophrenia to build trust and a therapeutic relationship. Constantly changing staff assignments can lead to increased anxiety and mistrust.
D. Assign an assistive personnel to feed the client at meal times:
While assistance with feeding may be needed, assigning an assistive personnel without direct supervision for a client with paranoid schizophrenia may not be the best approach. It's important to ensure the client's safety and monitor their behavior during meals.
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Related Questions
Correct Answer is D
Explanation
A. Implement the client's behavioral modification plan:
While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.
B. Document the size and location of the cuts:
Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.
C. Administer a tetanus antitoxin:
Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.
D. Inspect the cuts for debris:
This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.
Correct Answer is C
Explanation
A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications: The symptoms described (uncontrollable tongue movements, stiff neck, difficulty swallowing) are more indicative of tardive dyskinesia than neuroleptic malignant syndrome. Neuroleptic malignant syndrome is characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity. Treatment involves discontinuing antipsychotic medications and supportive care.
B. Agranulocytosis treated by administration of clozapine (Clozaril): Agranulocytosis is a rare but serious side effect of clozapine, not a treatment for the symptoms described. The symptoms presented are more consistent with tardive dyskinesia.
C. Tardive dyskinesia treated by discontinuing antipsychotic medication: This is the correct answer. Tardive dyskinesia is a movement disorder characterized by involuntary and abnormal movements, including tongue protrusion and facial grimacing. It can result from long-term use of antipsychotic medications, and discontinuing or reducing the dose of the antipsychotic is a primary intervention.
D. Headache treated by administration of Hydrochlorothiazide: Hydrochlorothiazide is a diuretic used to treat conditions like high blood pressure and edema, not headache or the symptoms described, which are more indicative of tardive dyskinesia.
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