A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Tell the client that there is nothing there.

Ask the client to describe what is being seen.

Touch the client's arm reassuringly.

Remove the client from the room.

Answer and Explanation

The Correct Answer is B

A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.

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Correct Answer is D

Explanation

A. "Obsessive-compulsive disorder.": Obsessive-compulsive disorder (OCD) is more commonly associated with cluster C personality disorders, particularly obsessive-compulsive personality disorder, which involves rigid perfectionism and a preoccupation with orderliness.
B. "Schizophrenia.": Schizophrenia is not a common comorbidity of cluster B personality disorders. It is more closely linked to schizotypal personality disorder, a cluster A disorder, which involves eccentric behaviors and cognitive distortions.
C. "General anxiety disorder.": Generalized anxiety disorder (GAD) is more frequently seen in cluster C personality disorders, such as avoidant and dependent personality disorders, which are characterized by excessive fearfulness and anxiety-driven behaviors.
D. "Anorexia nervosa.": Anorexia nervosa is commonly comorbid with cluster B personality disorders, particularly borderline personality disorder, due to emotional dysregulation, impulsivity, and an intense fear of abandonment that can contribute to disordered eating behaviors.

A. Strict parental guidelines contribute to the development of personality disorders. B. Personality disorders often manifest from childhood emotional trauma. C. Clients of higher socioeconomic status are less likely to be diagnosed with personality disorders. D. Personality disorders are often seen in children under the age of 10.

Correct Answer is B

Explanation

A. Strict parental guidelines contribute to the development of personality disorders: While parenting style can influence personality development, strict guidelines alone do not directly cause personality disorders. Genetic, environmental, and social factors interact to contribute to their onset.
B. Personality disorders often manifest from childhood emotional trauma: Childhood emotional trauma, including neglect, abuse, and unstable relationships, is a significant risk factor for personality disorders. These experiences can lead to maladaptive coping mechanisms that persist into adulthood.
C. Clients of higher socioeconomic status are less likely to be diagnosed with personality disorders: Personality disorders occur across all socioeconomic backgrounds. Diagnosis may be influenced by access to mental health care, but the prevalence is not necessarily lower in higher socioeconomic groups.
D. Personality disorders are often seen in children under the age of 10: Personality disorders are not typically diagnosed in children because personality development is ongoing. Diagnosis usually occurs in late adolescence or early adulthood when patterns of behavior become persistent and disruptive.

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A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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