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.

Answer and Explanation

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:

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.
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.
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.

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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.

A. Psychomotor retardation. B. Decreased self-esteem. C. Euphoria. D. Hallucinations. E. Hallucinations.

Correct Answer is C

Explanation

Choice A rationale:

Psychomotor retardation is a characteristic of depression, not hypomania. In fact, individuals with hypomania typically exhibit psychomotor agitation, which is characterized by increased energy and activity levels.

Psychomotor retardation often manifests as slowed movements, speech, and thought processes. It can significantly impact an individual's ability to perform daily tasks and engage in social interactions.

While psychomotor retardation can occur in various mental health conditions, it is not typically associated with hypomania.

Choice B rationale:

Decreased self-esteem is also a characteristic of depression, not hypomania. Individuals with hypomania typically experience inflated self-esteem and grandiosity.

They may overestimate their abilities, make unrealistic plans, or engage in risky behaviors. This inflated sense of self-worth is often a hallmark feature of hypomania and can contribute to impaired judgment and decision-making.

Choice C rationale:

Euphoria is a hallmark symptom of hypomania. It is characterized by an elevated, expansive, or irritable mood that is persistent and noticeable to others.

Individuals with euphoria often feel excessively happy, cheerful, or optimistic. They may have increased energy, decreased need for sleep, and a heightened sense of well-being.

They may also be more talkative, outgoing, and engage in pleasurable activities more often.

This elevated mood is a core feature of hypomania and is often accompanied by other characteristic symptoms, such as increased activity levels, racing thoughts, and impulsivity.

Choice D rationale:

Hallucinations are not a typical feature of hypomania. They are more commonly associated with psychotic disorders, such as schizophrenia.

Hallucinations involve perceiving things that are not real, such as hearing voices or seeing things that are not there.

While hallucinations can occur in some individuals with hypomania, they are not a defining feature of the condition

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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?

Explanation:

Why the other options are incorrect:

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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?