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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The nurse should notify the provider because this value is lower than the normal range of 150,000 to 450,000 platelets per microliter of blood. A low platelet count can indicate a risk of bleeding or a condition such as thrombocytopenia or disseminated intravascular coagulation (DIC).

Choice B is wrong because WBC count 9,800/mm³ is within the normal range of 4,500 to 11,000 cells per microliter of blood.

Choice C is wrong because Hgb 13 mg/dL is within the normal range of 12 to 16 mg/dL for females and 14 to 18 mg/dL for males.

Choice D is wrong because Hct 42% is within the normal range of 37% to 47% for females and 42% to 52% for males.

A. Check the back of the throat with a pen light. B. Obtain the child’s vital signs in 15 min. C. Administer analgesia. D. Offer the child a drink of water.

Correct Answer is A

Explanation

A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory values for an adolescent who is scheduled for a surgical procedure. For which of the following laboratory values should the nurse notify the provider?

Correct Answer is A

Explanation

A nurse is caring for a preschooler immediately following a tonsillectomy and notices the child swallowing frequently. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

A nurse is reinforcing teaching with a client who has gestational diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?

A charge nurse is observing a newly licensed nurse administer an enteral feeding to a client who has an established gastrostomy tube. Which of the following actions by the newly licensed nurse indicates that the charge nurse should intervene?

A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder. Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

A nurse is reinforcing home safety instructions with the guardian of an 18-month- old toddler. Which of the following responses by the guardian indicates an understanding of the teaching?

A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania. Which of the following findings should the nurse expect? (Select all that apply.).

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?