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?

Choice A rationale:

Ideas of reference are a type of delusion in which a person believes that unrelated events, objects, or actions in the environment have personal significance or meaning specifically directed towards them. In this case, the client with schizophrenia misinterpreted the group's laughter as mockery directed specifically at them, even though the story was unrelated to them.

Here's a detailed explanation of why the other choices are incorrect: B. Grandeur:

Grandiosity involves an inflated sense of self-importance, power, or identity. It's not evident in this scenario, as the client isn't expressing beliefs of exceptional abilities or status. C. Somatic delusion:

Somatic delusions focus on bodily functions or sensations, such as believing organs are rotting or insects are crawling under the skin. The client's outburst isn't related to bodily concerns. D. Erotomania:

Erotomania is a delusion where a person believes someone of higher status is in love with them. It's not applicable in this situation as the client's belief isn't about romantic interest.

Choice D rationale:

Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.

Blurred vision and nausea are common early symptoms of lithium toxicity.

Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.

The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.

The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.

Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.

Choice A rationale:

Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.

It is important for the nurse to take more decisive action to prevent further toxicity.

Choice B rationale:

Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.

It is important for the nurse to take immediate action to protect the client's health.

Choice C rationale:

Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.

This is not a safe or appropriate action for the nurse to take in this situation.