A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Set limits on the amount of time the client talks about delusions,

Schedule a variety of competitive stimulating group activities for the client

Tell the client that the delusions are not real

Avoid asking the client about triggers for the delusions

Answer and Explanation

The Correct Answer is A

A. Set limits on the amount of time the client talks about delusions. Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.

B. Schedule a variety of competitive stimulating group activities for the client. Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.

C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.

D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.

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Correct Answer is D

Explanation

A. Requesting an appointment to discuss depression is an indication that the client is seeking help, which is a positive step. It does not necessarily indicate an immediate risk of suicide.

B. Stating that they are stopping their medication raises concerns about treatment compliance, but it does not provide a clear indication of suicidal intent. It is important to assess the reasons for discontinuing medication and address any concerns.

C. Sleeping 12 hours a day can be a symptom of depression, but it does not necessarily indicate an immediate risk of suicide. It is crucial to assess the client's overall mental health and functioning.

D. A client who is giving away their possessions.
Giving away possessions can be a warning sign of suicidal intent. This behavior may indicate that the individual is preparing for the possibility of not needing those belongings in the future. It is crucial for the nurse to assess and intervene promptly if a client is exhibiting signs of suicidality.

A. Focusing attention on useful tasks. B. Manipulating and controlling others behavior. C. decreasing anxiety to a tolerable level. D. Limiting the amount of time available for interaction with others

Correct Answer is C

Explanation

A. Focusing attention on useful tasks: While the client's actions involve tasks, the primary motivation is to reduce anxiety rather than simply focusing attention on useful tasks for their own sake.

B. Manipulating and controlling others' behavior: The client's behavior is more related to managing their own anxiety through compulsive actions rather than manipulating or controlling others.

C. Decreasing anxiety to a tolerable level.
In obsessive-compulsive disorder (OCD), individuals often engage in repetitive and ritualistic behaviors as a way to manage anxiety. The compulsive behaviors, such as cleaning and picking up after others in this case, serve as a mechanism to reduce anxiety or prevent a feared event. These actions may provide a sense of control and temporary relief from obsessive thoughts.

D. Limiting the amount of time available for interaction with others: While the client's compulsive behaviors may limit social interactions, the primary purpose is to manage anxiety rather than intentionally limiting interaction with others.

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A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

Correct Answer is D

Explanation

A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

Correct Answer is C

Explanation

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