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

Promote interaction with others.

Encourage participation in group therapy activities.

Decrease their anxiety and increase trust.

Improve their relationship with their parents.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is B

Explanation

Choice B Reason: Assess for environmental triggers and potential unmet needs.

Choice A Reason:

Consulting the interdisciplinary team regarding behavior modification techniques is important for long-term management of behavioral problems in clients with major neurocognitive disorder. However, it is not the immediate priority when a client is exhibiting acute behavioral escalation. Immediate assessment and intervention are necessary to address the current situation and ensure the client’s safety.

Choice B Reason:

Assessing for environmental triggers and potential unmet needs is the priority in this scenario. Clients with major neurocognitive disorder often exhibit behavioral problems due to unmet needs or environmental factors that they cannot communicate effectively. Identifying and addressing these triggers can help de-escalate the situation and prevent further agitation. This approach aligns with evidence-based practice, which emphasizes understanding the underlying causes of behavioral issues to provide appropriate interventions.

Choice C Reason:

Assessing for potential injury to the client’s arms, legs, and back is crucial, especially if the client is on the ground and exhibiting aggressive behavior. However, this assessment should follow the initial step of identifying and addressing environmental triggers and unmet needs. Ensuring the client’s immediate safety by understanding the cause of their behavior is the first priority.

Choice D Reason:

Anticipating the behavior and physically restraining the client when pacing begins is not recommended as the first line of action. Physical restraint should be a last resort due to the potential for causing harm and increasing the client’s agitation. Instead, non-pharmacological interventions, such as identifying triggers and unmet needs, should be prioritized to manage the behavior safely and effectively.

A. “There is no such thing as the devil. It’s all in your mind.” B. “You are not going to hell. You are a good person.” C. “Did you take your medicine this morning?” D. “The voices sound distressing, but I don’t hear them.”

Correct Answer is D

Explanation

Choice A Reason:

“There is no such thing as the devil. It’s all in your mind.”

This response dismisses the client’s experience and can make them feel invalidated. Telling the client that their experience is “all in your mind” does not acknowledge their distress and can increase their feelings of isolation and mistrust. It is important to validate the client’s feelings while gently orienting them to reality.

Choice B Reason:

“You are not going to hell. You are a good person.”

While this response is supportive, it does not address the client’s immediate distress about hearing voices. It is important to acknowledge the client’s experience of hearing voices and provide reassurance in a way that helps them feel understood and supported. Simply telling them they are a good person may not alleviate their anxiety about the voices.

Choice C Reason:

“Did you take your medicine this morning?”

Asking about medication adherence is important, but it is not the most appropriate immediate response to the client’s distress. This question can come across as dismissive and may not provide the immediate comfort and validation the client needs. It is better to first acknowledge the client’s experience and then address medication adherence later.

Choice D Reason:

“The voices sound distressing, but I don’t hear them.”

This is the correct response. It acknowledges the client’s distress and validates their experience without reinforcing the delusion. By stating that the nurse does not hear the voices, it gently orients the client to reality while showing empathy and understanding. This approach helps build trust and provides comfort to the client.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems. At the change of shift, the client’s behavior escalates from pacing in the hallway to screaming and waving their arms while on the ground. Which of the following represents a priority for the nurse?

Correct Answer is B

Explanation

A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

Correct Answer is D

Explanation

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