A client with a history of schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. Which intervention should the nurse implement?
Tell the client that irrational thinking is a symptom of schizophrenia.
Assure the client that all food served in the hospital is safe to eat.
Provide the client with food in unopened containers.
Obtain an order for a tube feeding for the client.
The Correct Answer is C
Choice A rationale: Telling the client that irrational thinking is a symptom of schizophrenia may not be well-received and could lead to increased resistance. It is essential to address the immediate concern of food refusal.
Choice B rationale: Assuring the client that all food served in the hospital is safe to eat may not be sufficient, especially if the client has strong delusional beliefs about poisoning. Offering food in unopened containers is a more practical approach. Choice C rationale: Providing the client with food in unopened containers is a reasonable intervention. It addresses the client's concerns about poisoning and ensures that the food is perceived as safe.
Choice D rationale: Obtaining an order for a tube feeding for the client may be considered if the client continues to refuse solid food. However, providing food in unopened containers is an initial step to encourage the client to eat.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: "You may think you are fat, but you look thin to me" is dismissive and may invalidate the client's feelings. It is essential to explore the client's emotions rather than providing a judgmental response.
Choice B rationale: "There are consequences for not eating" is confrontational and may increase the client's anxiety. A more therapeutic approach involves exploring the client's feelings and concerns about eating.
Choice C rationale: "Explain how you feel when it is time to eat" is an open-ended and non-judgmental response. It encourages the client to express her emotions, providing valuable information for further assessment and care planning.
Choice D rationale: "You must eat or you will become very sick" is directive and may increase resistance. It is essential to explore the client's feelings and collaborate on a plan rather than issuing directives.
Correct Answer is B
Explanation
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
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