A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Ask the client, “What are the voices saying to you?”

Give the client a PRN dose of benztropine.

Call and report the behavior to the physician.

Tell the client, “Well, I see you’re distracted right now. We’ll talk more later.”

Answer and Explanation

The Correct Answer is A

The correct answer is a.

Choice A Reason:

The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:

The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.

Choice C Reason:

The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.

Choice D Reason:

The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.

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Correct Answer is C

Explanation

Choice A Reason:

Promote interaction with others.

While promoting interaction with others is important for clients with schizophrenia, it is not the primary priority. Social interaction can help improve social skills and reduce isolation, but it should come after establishing a sense of safety and trust. Clients with schizophrenia often experience significant anxiety and mistrust, which need to be addressed first to create a stable foundation for further therapeutic interventions.

Choice B Reason:

Encourage participation in group therapy activities.

Encouraging participation in group therapy activities is beneficial for clients with schizophrenia as it can provide support and help them develop social skills. However, similar to promoting interaction with others, this goal is secondary to decreasing anxiety and building trust. Clients need to feel safe and trust their caregivers before they can effectively engage in group therapy.

Choice C Reason:

Decrease their anxiety and increase trust.

This is the correct response. Decreasing anxiety and increasing trust are fundamental goals in the care of clients with schizophrenia. High levels of anxiety and mistrust can exacerbate symptoms and hinder the effectiveness of other therapeutic interventions. Establishing a trusting relationship and reducing anxiety can create a more stable and supportive environment, which is essential for the client’s overall well-being and progress.

Choice D Reason:

Improve their relationship with their parents.

Improving the client’s relationship with their parents can be an important aspect of their overall treatment plan, especially if family dynamics contribute to their condition. However, this goal is not the immediate priority. Addressing the client’s anxiety and building trust should come first, as these are critical for the client’s stability and ability to engage in family therapy effectively.

A. The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms. B. Previous experiences, the availability of medication, and the desire to cope. C. Faith in the psychiatrist, the availability of financial resources, and previous level of functioning. D. The time of day, the client’s mood, and the availability of escape from the situation.

Correct Answer is A

Explanation

Choice A Reason:

The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms.

This is the correct response. A client’s perception of a stressful event plays a crucial role in determining whether they experience a crisis. If the client views the event as overwhelming and beyond their ability to cope, they are more likely to experience a crisis. Additionally, the availability of social supports, such as family, friends, and community resources, can provide emotional and practical assistance, reducing the likelihood of a crisis. Adequate coping mechanisms, such as problem-solving skills, emotional regulation, and stress management techniques, also play a significant role in helping the client manage stress effectively.

Choice B Reason:

Previous experiences, the availability of medication, and the desire to cope.

While previous experiences can influence how a client responds to stress, they are not the sole determinants of whether a crisis will occur. The availability of medication can help manage symptoms of stress or anxiety, but it does not address the underlying perception of the event or the availability of supports. The desire to cope is important, but without adequate coping mechanisms and support, it may not be sufficient to prevent a crisis.

Choice C Reason:

Faith in the psychiatrist, the availability of financial resources, and previous level of functioning.

Faith in the psychiatrist and the availability of financial resources can provide some support, but they do not directly address the client’s perception of the event or their coping mechanisms. Previous level of functioning is important, but it is not the primary factor in determining whether a crisis will occur. The client’s current perception and available supports are more critical in this context.

Choice D Reason:

The time of day, the client’s mood, and the availability of escape from the situation.

The time of day and the client’s mood can influence their immediate response to stress, but they are not the primary determinants of whether a crisis will occur. The availability of escape from the situation may provide temporary relief, but it does not address the underlying perception of the event or the availability of supports and coping mechanisms.

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A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with schizophrenia. Which of the following would be a priority nursing goal for this client’s care?

Correct Answer is C

Explanation

The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:

Correct Answer is A

Explanation

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