A nurse is developing a plan of care 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?

Use frequent touch to provide client support.

Directly tell the client that delusions are not real

Limit the number of questions asked during assessments

Place the client in seclusion visual hallucinations are present

Answer and Explanation

The Correct Answer is C

A. Using frequent touch to provide client support: While touch can be comforting for some clients, individuals with schizophrenia, especially those experiencing paranoid delusions, may interpret touch as threatening or intrusive. Therefore, using frequent touch may exacerbate the client's paranoia and increase their distress.

B. Directly telling the client that delusions are not real: Directly challenging the client's delusions may cause them to become defensive or agitated. It is unlikely to be effective in changing the client's beliefs and may damage the therapeutic relationship. Instead, the nurse should use therapeutic communication techniques to explore the client's perceptions and validate their feelings while gently offering alternative perspectives.

C. Limiting the number of questions asked during assessments: Individuals experiencing frequent hallucinations and paranoid delusions may have difficulty concentrating and processing information. Limiting the number of questions asked during assessments reduces cognitive overload and helps prevent overwhelming the client. The nurse should prioritize asking clear, concise questions relevant to the client's immediate needs.

D. Placing the client in seclusion if visual hallucinations are present: Seclusion should only be used as a last resort and when absolutely necessary to ensure the safety of the client or others. It is not an appropriate intervention for managing hallucinations alone. Instead, the nurse should employ therapeutic communication techniques, provide a safe and supportive environment, and use prescribed medications as indicated to manage the client's symptoms.

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Correct Answer is B

Explanation

A. A semi-private room with a roommate who has a similar diagnosis. Placing a client experiencing a manic episode in a semi-private room with another client who also has a similar diagnosis could potentially exacerbate symptoms or lead to conflict. Manic clients may have increased energy levels, impulsivity, and decreased need for sleep, which could disrupt the roommate's rest and compromise their safety.

B. A private room close to the nursing station. Assigning a private room close to the nursing station is the most appropriate option for a client in the manic phase of bipolar disorder. This allows for closer monitoring and supervision by nursing staff, as well as easier access for interventions and assistance when needed. It also helps to minimize stimulation and provide a more controlled environment for the client.

C. A private room in a quiet location on the unit. While a quiet location may be beneficial for some clients, a private room close to the nursing station offers better access to supervision and support from staff, which is particularly important for clients experiencing mania. Additionally, a quiet location may not always be feasible in a busy psychiatric unit.

D. A seclusion room until the client's activity level becomes more subdued. Using a seclusion room should only be considered as a last resort and when absolutely necessary to ensure the safety of the client and others. It should not be the first choice for a client in the manic phase of bipolar disorder. Placing the client in seclusion may further escalate agitation and increase feelings of isolation and distress.

A. "Try switching to a different formula. " B. "Burp your baby more frequently during feedings." C. "Bring your baby in to the clinic today." D. "Give your infant an oral rehydration solution."

Correct Answer is C

Explanation

A. "Try switching to a different formula." While switching formula might be an option if the infant is having feeding issues, projectile vomiting in a 2-month-old infant could indicate a more serious condition, such as pyloric stenosis. It's essential for the nurse to assess the infant's condition in person rather than recommending a formula change over the phone.

B. "Burp your baby more frequently during feedings." Burping the baby more frequently might help reduce gas but is unlikely to resolve projectile vomiting, which can be a sign of a medical issue requiring prompt attention.

C. "Bring your baby in to the clinic today." This response is the most appropriate because projectile vomiting in an infant, especially when combined with increased hunger, could indicate a serious condition like pyloric stenosis or other gastrointestinal problems. The infant needs to be assessed by a healthcare provider as soon as possible to determine the cause and initiate appropriate treatment.

D. "Give your infant an oral rehydration solution." Oral rehydration solutions are typically used to replenish fluids lost due to vomiting or diarrhea. However, in this case, the priority is to determine the cause of the projectile vomiting, which requires a thorough assessment by a healthcare provider.

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A nurse is developing a plan of care 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 is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?

Correct Answer is B

Explanation

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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