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 C

Explanation

A. "Avoid foods that contain tyramine" is not relevant to fluoxetine. Tyramine restriction is a concern with certain medications, such as monoamine oxidase inhibitors (MAOIs), but not with SSRIs like fluoxetine.

B. "Plan to discontinue this medication as soon as your depression is relieved" is not advisable. Discontinuing an antidepressant abruptly can lead to withdrawal symptoms and may not allow for the full resolution of depressive symptoms. The decision to discontinue medication should be made in consultation with a healthcare provider.

C. "Expect that your mood might take one to three weeks to begin improving" is a crucial piece of information to provide because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), often takes a few weeks to start exerting its therapeutic effects. It's important for the client to understand that the full benefits of the medication may not be felt immediately.

D. "Stop taking this medication if weight loss or gain occurs" is not an appropriate instruction. Weight changes are potential side effects of fluoxetine, but the decision to continue or discontinue the medication should be based on consultation with a healthcare provider. Abruptly stopping medication without medical guidance can lead to withdrawal symptoms and is not recommended.

A. Whether the client is a danger to herself or others. B. Whether the client is unwilling to accept that treatment is needed. C. Whether the client is financially incapable of paying for prescribed medications. D. Whether the client is unable to make arrangements to stay with someone

Correct Answer is A

Explanation

A. The criteria for involuntary commitment typically involve assessing whether the individual presents a danger to themselves or others. If the client continues to pose a significant risk of harm to themselves or others, the involuntary hold may be extended.

B. Whether the client is unwilling to accept that treatment is needed is relevant to the overall treatment plan, but it may not be the primary criterion for involuntary commitment. The focus is often on the immediate risk of harm.

C. Whether the client is financially incapable of paying for prescribed medications is not typically a consideration in the decision to extend an involuntary hold. The decision is primarily based on the risk of harm to the client or others.

D. Whether the client is unable to make arrangements to stay with someone is not a primary criterion for involuntary commitment. The decision is based on the assessment of the client's immediate danger to themselves or 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 reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse Include?

Correct Answer is C

Explanation

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Correct Answer is A

Explanation

A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)

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?

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