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. Exploring reasons for her behavior is important for understanding the underlying issues, but the immediate priority is to ensure the client's safety.

B. Providing strategies for redirecting violent behavior is a relevant intervention, but it is not the priority in this situation. Safety concerns related to self-harm take precedence.

C. Encouraging the client to talk about her feelings is a valuable therapeutic intervention, but in the context of borderline personality disorder, the immediate priority is to address the risk of self-harm. Once the client's safety is ensured, exploring feelings and developing coping strategies can be part of the ongoing therapeutic process.

D. Protecting the client from self-harm behavior is the priority because individuals with borderline personality disorder are at an increased risk of engaging in self-harming behaviors,

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort

Explanation:

St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.

In the given scenario, the nurse should identify:

Condition: The client's intake of St. John's wort

Client Finding: At risk for developing serotonin syndrome

This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.

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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 assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?

Correct Answer is D

Explanation

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

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