The nurse is caring for a client diagnosed with catatonia. Which of the following should be a priority action by the nurse?
Schedule the client for a therapeutic group session.
Encourage the client to walk in the hallway.
Encourage the client to verbalize feelings at all times.
Offer small, frequent fluids throughout the day.
The Correct Answer is D
Choice A Reason:
Scheduling the client for a therapeutic group session may not be appropriate as a priority action. Clients with catatonia often experience significant psychomotor disturbances, which can include immobility or stupor, making participation in group activities challenging and potentially distressing.
Choice B Reason:
Encouraging the client to walk in the hallway is not the most immediate concern. While mobility is important, the safety and medical stability of the client take precedence, especially considering the potential for immobility and resistance to movement in catatonic states.
Choice C Reason:
Encouraging the client to verbalize feelings at all times is not practical as a priority action. Catatonia can involve mutism or significantly reduced responsiveness, making it difficult for the client to express themselves verbally.
Choice D Reason:
Offering small, frequent fluids throughout the day is a priority action for a client with catatonia. Due to the potential for decreased oral intake and the risk of dehydration, ensuring the client receives adequate hydration is essential. This intervention addresses a basic physiological need and can prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Negative Operant Conditioning involves the removal of an unpleasant stimulus to increase the likelihood of a behavior being repeated. In this scenario, the nurse is not removing an unpleasant stimulus but is instead taking over a task to prevent conflict, which does not align with the principles of negative operant conditioning.
Choice B reason:
Positive Role Modeling is demonstrated when an individual exhibits behavior that is beneficial and can be emulated by others. By taking the tray to avoid conflict, the nurse is showing understanding and flexibility, qualities that are positive and can be modeled in a healthcare setting.
Choice C reason:
Aggressiveness is characterized by hostile or forceful behavior or attitudes. The nurse's action of taking the tray to the kitchen is not aggressive; it is a non-confrontational approach to managing the situation.
Choice D reason:
Assertiveness involves standing up for one's own rights in a direct, honest way, while also respecting the rights of others. The nurse's behavior is not assertive, as they are not addressing the client's refusal directly but are instead choosing to complete the task themselves to avoid confrontation.
Correct Answer is A
Explanation
Choice A Reason:
Providing continuity of care by assigning the same staff is essential in creating a therapeutic environment. It allows for the development of trust and rapport, which are foundational for effective mental health treatment. Consistent caregivers can better understand the clients' needs and tailor interventions accordingly.
Choice B Reason:
While it is important to be open to discussing various topics, the nurse must ensure that discussions remain therapeutic and relevant to treatment goals. Some topics may need to be redirected or limited to maintain a safe and supportive environment.
Choice C Reason:
Allowing clients to determine the boundaries of the nurse-client relationship could lead to blurred lines that may affect the quality of care. It is the nurse's responsibility to establish clear professional boundaries while being empathetic and supportive.
Choice D Reason:
Focusing on client wellness is a broad concept that encompasses the clients' physical, mental, and social well-being. It is a goal of the therapeutic environment to promote overall wellness, but specific strategies are needed to achieve this aim.
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