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

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Less-restrictive alternatives have been tried without success: While it is important to explore less-restrictive alternatives before resorting to medication, the immediate concern is the client's safety and the safety of others. If the client's behavior poses a significant risk, prompt intervention may be necessary.

B. The medication will make the work of the staff easier or safer: While staff safety is important, the primary consideration for administering a prn dose of Haloperidol is the clinical need based on the client's behavior and potential danger to themselves, others, or the environment.

C. The client is willing to accept the medication: Client willingness to accept medication is relevant for promoting collaboration in treatment, but the urgency in administering a prn dose is often based on the client's behavior and the level of risk they pose.

D. The client's behavior indicates possible danger to self, others, or the environment: This is the most critical factor in determining the need for a prn dose. If a client's behavior poses a significant risk, such as aggression, violence, or extreme agitation, administering a prn dose of medication may be necessary to ensure safety and prevent harm.

A. Provide personal space to respect the clients boundaries B. Maintain continual eye contact throughout the interview C. Provide neon lights and soft music D. use therapeutic touch to increase trust and rapport

Correct Answer is A

Explanation

A. Provide personal space to respect the client's boundaries: This is the correct answer. Personal space is crucial when caring for an agitated client with paranoia. Respecting the client's need for distance helps to reduce anxiety and prevent escalation of agitation.

B. Maintain continual eye contact throughout the interview: Continuous eye contact may be perceived as confrontational and can increase anxiety, especially in individuals with paranoia. It is important to be mindful of non-verbal cues and adapt the approach to the client's comfort level.

C. Provide neon lights and soft music: Introducing external stimuli like neon lights and music may not be appropriate for an agitated client with paranoia. It could potentially exacerbate their distress. The focus should be on creating a calm and non-threatening environment.

D. Use therapeutic touch to increase trust and rapport: While therapeutic touch can be beneficial in certain situations, it may not be suitable for a client experiencing paranoia. Touch can be perceived as intrusive and may escalate agitation in this context.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

Correct Answer is D

Explanation

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

Correct Answer is A

Explanation

A nurse is teaching about sources of psychological stress to a group of newly licensed nurses. The nurse should identify which of the following qualifies as a source of psychological distress?

A new nurse is reviewing the various types of groups available on her new unit. One group adds new members as others leave. She recognizes this type of group as a(n) group?

Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)?

A nurse is caring for a client who has schizophrenia and tells the nurse. "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?

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?

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?