A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Directly tell the client that the delusions are not real.

Use frequent touch to provide client support.

Place the client in seclusion if visual hallucinations are present.

Limit the number of questions asked during assessments.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.

Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.

Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.

Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.

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Correct Answer is ["A","D"]

Explanation

Choice A Reason:
Blunted affect refers to a significant reduction in the intensity of emotional expression. In the context of schizophrenia, a person with blunted affect may show less facial expression, have diminished expressive gestures, and a monotone voice. This symptom reflects a decrease in the expression of emotions, which is characteristic of the negative symptoms of schizophrenia.

Choice B Reason:
Delusions are a type of positive symptom of schizophrenia, not a negative one. They are false beliefs that are not based in reality, such as thinking one has superpowers or is being persecuted. Delusions represent an excess or distortion of normal functions.

Choice C Reason:
Poor judgment is not typically classified as a negative symptom of schizophrenia. It can be a consequence of cognitive impairments or positive symptoms like delusions but is not a negative symptom itself.

Choice D Reason:
Anhedonia is the inability to feel pleasure and is a core negative symptom of schizophrenia. Individuals with anhedonia may not enjoy activities that they used to find pleasurable, which can significantly impact their quality of life.

Choice E Reason:
Hallucinations, like delusions, are considered positive symptoms of schizophrenia. They involve experiencing sensations that are not present, such as hearing voices or seeing things that others do not see.

A. Talk to the client and identify the specific limits that are required of the client's behavior. B. Discuss the problem in a community meeting with the other clients on the unit present. C. Escort the client to her room each time the nurse observes the client socializing with other clients. D. Tell the other clients to ignore the client's lies.

Correct Answer is A

Explanation

Choice A reason:
Talking directly to the client and setting clear boundaries is a therapeutic approach. It respects the client's autonomy while also addressing the behavior that is affecting the therapeutic environment. By identifying specific limits, the nurse helps the client understand the consequences of their actions and the importance of maintaining a respectful and honest communication with others.

Choice B reason:
Discussing the problem in a community meeting could be helpful, but it should not be the initial action. This approach might inadvertently shame or embarrass the client in front of peers, which could exacerbate the situation. It's important to address the behavior privately before involving the larger group.

Choice C reason:
Escorting the client to their room each time they socialize could be seen as punitive and may not address the underlying reasons for the lying behavior. It could also isolate the client from social interactions that are an essential part of the healing process.

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A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Correct Answer is A

Explanation

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