A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?

Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.

Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.

Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.

Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.

The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.

Face the client at eye level when communicating.

This is because eye contact helps to establish rapport and trust with the client who has dementia and shows respect and attention. Facing the client at eye level also reduces distractions and background noise that might interfere with communication.

Choice B is wrong because offering correction of incorrect client statements can increase confusion, frustration, and agitation in the client who has dementia. Instead of correcting the client, the nurse should acknowledge their feelings and try to understand their perspective.

Choice C is wrong because reorienting the client to date and time with each encounter can be stressful and ineffective for the client who has dementia. Reorientation may work in the early stages of dementia, but as the disease progresses, the client may lose their ability to retain new information and may become more disoriented. Instead of reorienting the client, the nurse should use orienting names or labels whenever possible, such as “Your son, Jack” .

Choice D is wrong because avoiding using gestures when communicating with the client who has dementia can limit the nurse’s ability to convey meaning and emotion. Gestures can help to supplement verbal communication and provide cues for the client who has difficulty understanding words. However, the nurse should avoid using gestures that might be misinterpreted or threatening to the client, such as pointing or waving .