A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.
Which of the following is the priority nursing intervention for this client?
Ensure the client goes to group activities as planned.
Use distraction such as the television or music.
Provide reassurance and comfort ensuring the client is safe.
Give PRN medications to treat increased hallucinations.
The Correct Answer is C
Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.
Correct Answer is D
Explanation
Choice A rationale:
Encouraging family to take the client out of the facility for short periods of time can be beneficial, but it does not address the sudden change in behavior.
Choice B rationale:
Rewarding the client for her change in behavior can reinforce positive behavior, but it does not address the sudden change in behavior.
Choice C rationale:
Asking the client why her behavior has changed can provide insight, but it does not ensure the safety of the client.
Choice D rationale:
Monitoring the client’s whereabouts at all times is important as a sudden change in mood can indicate a higher risk of suicide.
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