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 C

Explanation

Choice A reason:
This statement may come across as dismissive of the potential benefits of medication, which can be an important part of treatment for some individuals. It's essential to consider and respect each client's unique treatment needs, including medication.

Choice B reason:
Pointing out physical manifestations of stress in a confrontational way may make the client feel self-conscious or defensive. It's important to address such observations with sensitivity and in the context of exploring feelings.

Choice C reason:
Inviting the client to discuss their concerns about returning to work opens up a dialogue about their fears and challenges. It's a supportive approach that encourages expression and exploration of feelings.

Choice D reason:
While resolving conflicts is important, this directive statement may feel overwhelming to a client who is already dealing with a new cancer diagnosis. It's better to offer support and guidance in navigating interpersonal issues.

A. A mental health unit, which includes milieu therapy, is focused on stabilizing clients who are in an acute phase of mental illness. B. A mental health unit, which includes milieu therapy, is less intensive, focusing only on one psychiatric illness or substance abuse disorder. C. A mental health unit, which includes milieu therapy, ensures every aspect of care is intentionally focused on creating a safe and therapeutic environment. D. A mental health unit, which includes milieu therapy, is focused on long-term care of clients who have specific mental health disorders.

Correct Answer is C

Explanation

Choice A reason:
While a mental health unit that includes milieu therapy may focus on stabilizing clients, it is not limited to those in an acute phase of mental illness. Milieu therapy is a comprehensive approach that can benefit individuals at various stages of their treatment.

Choice B reason:
Milieu therapy is not necessarily less intensive nor does it focus solely on one psychiatric illness or substance abuse disorder. It is a versatile treatment method that can be applied to a range of conditions and is integrated into the daily life of the unit.

Choice C reason:
This choice accurately reflects the essence of milieu therapy. It is a therapeutic approach where the environment is used as an integral part of treatment. The goal is to create a stable, adaptive reality through routines, boundaries, and open communication, fostering a sense of safety and support for therapeutic change.

Choice D reason:
Milieu therapy is not exclusively focused on long-term care but is adaptable to the needs of clients, whether they require short-term stabilization or long-term treatment. It is designed to help individuals learn healthier ways of thinking and behaving within a supportive community setting.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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