A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior.
Which of the following interventions should the nurse recommend to be included in the plan of care?
Place the client in seclusion if she is experiencing visual hallucinations.
Minimize staff supervision of the client’s interactions with others.
Directly tell the client that delusions are not real.
Limit the client’s participation in group activities.
The Correct Answer is D
The correct answer is D. Limit the client’s participation in group activities.
Explanation:
Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.
Why the other options are incorrect:
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A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
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B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
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C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
I will contact my provider if I have difficulty urinating.
Chlorpromazine has anticholinergic effects, which can cause urinary retention. This means the medication can interfere with the normal function of the bladder, making it difficult to empty completely. Difficulty urinating can lead to bladder distention, urinary tract infections, and even kidney damage if left untreated.
It's crucial for the client to recognize this potential side effect and seek medical attention promptly if it occurs. Early intervention can help prevent complications and ensure proper bladder management.
By understanding this potential side effect and the importance of seeking help, the client demonstrates a grasp of the teaching provided.
Choice B rationale:
I might notice an increased frequency of my menstrual cycle.
Chlorpromazine does not typically affect menstrual frequency. While some antipsychotic medications can cause menstrual irregularities, chlorpromazine is not commonly associated with this effect.
If a client experiences changes in their menstrual cycle while taking chlorpromazine, it's important to discuss it with their healthcare provider to rule out other potential causes.
Choice C rationale:
These medications might cause breast tissue to atrophy.
Chlorpromazine is not known to cause breast atrophy. Breast atrophy, or shrinkage of breast tissue, can occur due to hormonal changes, aging, or certain medical conditions.
However, it's not a common side effect of chlorpromazine.
Choice D rationale:
I am at a decreased risk for infection while taking these medications.
Chlorpromazine does not decrease the risk of infection. In fact, it may slightly increase the risk of infection due to its potential to suppress the immune system.
It's essential for clients taking chlorpromazine to practice good hygiene and infection prevention measures to protect themselves from illness.
Correct Answer is C
Explanation
Choice A rationale:
Losing 10 lb after the death of a loved one is not uncommon, especially within the first few months of grieving. It can be due to decreased appetite, changes in eating habits, or increased physical activity. While it's important to monitor weight loss and ensure adequate nutrition, it doesn't necessarily indicate maladaptive grieving on its own.
Grief can often lead to changes in appetite and weight. Some people may experience a loss of appetite and unintentional weight loss, while others may find themselves overeating or gaining weight. These changes are often temporary and subside as the grieving process progresses.
It's important to consider the client's overall health and well-being when assessing weight loss. If the client is experiencing significant weight loss, it's important to rule out any underlying medical conditions that may be contributing to it.
Choice B rationale:
Visiting a loved one's grave is a common way to grieve and remember them. It can be a way to feel connected to the deceased, express love and sorrow, and find solace. It's a normal part of the grieving process and doesn't necessarily indicate maladaptive grieving.
Grieving individuals often find comfort in visiting the gravesite of their loved one. It can be a place to reflect, remember, and feel close to the deceased. Visiting a gravesite can also be a way to honor the loved one's memory and express continued love and respect.
The frequency of grave visits can vary from person to person. Some individuals may visit frequently, while others may only visit on special occasions or anniversaries. There is no right or wrong way to grieve, and what matters most is that the individual finds a way to express their grief in a way that feels right for them.
Choice D rationale:
Difficulty sleeping is a common symptom of grief. It can be caused by a variety of factors, including anxiety, sadness, and changes in sleep patterns. While it can be distressing, it's not always a sign of maladaptive grieving.
Grief can disrupt sleep patterns in a number of ways. It can make it difficult to fall asleep, stay asleep, or both. It can also lead to nightmares, night sweats, and early morning awakenings. These sleep disturbances can be both physically and emotionally draining.
There are a number of things that can be done to improve sleep during grief. These include establishing a regular sleep schedule, creating a relaxing bedtime routine, avoiding caffeine and alcohol, and getting regular exercise. If sleep problems persist, it's important to seek professional help.
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