The nurse is caring for a client in an acute mental health unit. The client states, “I believe my food is poisoned.” Which of the following should be an appropriate action by the nurse?
Taking steps to prevent the client from verbalizing the delusional thoughts.
Allowing the client to select food from vending machines.
Explaining that others eat the same food and feel safe.
Encouraging the client to discuss why someone would poison the food.
The Correct Answer is B
Choice A Reason:
Taking steps to prevent the client from verbalizing delusional thoughts is not therapeutic. It can lead to the client feeling misunderstood and unsupported. Nurses should provide a safe environment where clients feel comfortable expressing their thoughts and feelings.
Choice B Reason:
Allowing the client to select food from vending machines can be a temporary measure to address the immediate concern of the client’s fear of being poisoned. It provides a sense of control over their situation and may help to reduce anxiety related to eating.
Choice C Reason:
Simply explaining that others eat the same food and feel safe may not be effective for a client experiencing delusions. Delusions are fixed beliefs that are not easily changed by logical explanations or evidence to the contrary.
Choice D Reason:
Encouraging the client to discuss why someone would poison the food might validate the delusion and could reinforce the false belief. It’s important to acknowledge the client’s feelings without supporting the delusional content.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Blunted affect refers to a significant reduction in the intensity of emotional expression. In the context of schizophrenia, a person with blunted affect may show less facial expression, have diminished expressive gestures, and a monotone voice. This symptom reflects a decrease in the expression of emotions, which is characteristic of the negative symptoms of schizophrenia.
Choice B Reason:
Delusions are a type of positive symptom of schizophrenia, not a negative one. They are false beliefs that are not based in reality, such as thinking one has superpowers or is being persecuted. Delusions represent an excess or distortion of normal functions.
Choice C Reason:
Poor judgment is not typically classified as a negative symptom of schizophrenia. It can be a consequence of cognitive impairments or positive symptoms like delusions but is not a negative symptom itself.
Choice D Reason:
Anhedonia is the inability to feel pleasure and is a core negative symptom of schizophrenia. Individuals with anhedonia may not enjoy activities that they used to find pleasurable, which can significantly impact their quality of life.
Choice E Reason:
Hallucinations, like delusions, are considered positive symptoms of schizophrenia. They involve experiencing sensations that are not present, such as hearing voices or seeing things that others do not see.
Correct Answer is D
Explanation
Choice A reason:
Acute dystonia is characterized by sudden muscle contractions that can cause abnormal postures. While it is an adverse effect of antipsychotic medications, the symptoms typically include muscle spasms, stiffness, and oculogyric crisis, but not necessarily fever and diaphoresis.
Choice B reason:
Tardive dyskinesia is a late-onset movement disorder associated with prolonged use of antipsychotic medications. It presents with repetitive, involuntary, and purposeless movements, such as grimacing, tongue movements, and lip smacking. Fever and blood pressure changes are not typical features of tardive dyskinesia.
Choice C reason:
Pseudoparkinsonism is an adverse effect of antipsychotic medications that mimics the symptoms of Parkinson's disease, such as tremor, rigidity, bradykinesia, and postural instability. However, it does not usually present with fever or diaphoresis.
Choice D reason:
Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic emergency associated with the use of antipsychotic medications. It is characterized by mental status changes, muscle rigidity, fever, and autonomic dysfunction, such as blood pressure changes and diaphoresis. NMS requires immediate medical attention and discontinuation of the offending agent.
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