A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior.
Which of the following interventions should the nurse include in the initial plan?
Warn the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination.
Keep the facility’s security personnel constantly visible to the client throughout treatment.
Collaborate with the client to develop a daily physical exercise routine.
Agree that the hallucinations are real if the client exhibits aggressive behavior toward other clients.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“I will turn all pot handles toward the back of the stove.” This indicates that the guardian understands how to prevent the toddler from pulling a pot off the stove and getting burned.
Choice B is wrong because a child’s car seat should be rear-facing until the child is at least 2 years old or reaches the maximum height and weight for the seat.
Choice C is wrong because the temperature of the water heater should be set to no higher than 120 degrees to prevent scalding injuries.
Choice D is wrong because drop-side cribs are banned in the United States due to the risk of entrapment and suffocation.
Correct Answer is A
Explanation
Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.
Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.
Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.
Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.
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