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. Limit time for the client to perform activities. This intervention is not appropriate for a client with Alzheimer's disease. Limiting time for activities may increase agitation and frustration in individuals with cognitive impairments. Instead, it's important to allow adequate time for tasks and provide support as needed.

B. Talk the client through tasks one step at a time. This intervention is appropriate for a client with Alzheimer's disease. Breaking tasks into manageable steps and providing clear, simple instructions can help the client better understand and complete activities. This approach reduces confusion and frustration and promotes independence to the extent possible.

C. Provide an activity schedule that changes from day to day. Consistency is key in caring for individuals with Alzheimer's disease. A changing activity schedule may lead to increased confusion and disorientation. It's important to establish a routine and maintain consistency in daily activities and schedules to provide a sense of security and familiarity for the client.

D. Rotate assignment of daily caregivers. Consistency in caregiver assignments is essential for individuals with Alzheimer's disease. Changing caregivers frequently can disrupt the client's sense of security and increase confusion and anxiety. Continuity of care helps build trust and rapport between the client and caregivers, which is beneficial for the client's overall well-being.

A. Increased urinary output B. Anorexia C. Jaundice D. Diarrhea

Correct Answer is B

Explanation

A. Increased urinary output: Acute lead poisoning typically does not lead to increased urinary output. Instead, lead toxicity can affect renal function, potentially leading to kidney damage and decreased urinary output or even renal failure in severe cases.

B. Anorexia: Acute lead poisoning can lead to gastrointestinal symptoms such as abdominal pain, nausea, and vomiting, which can result in decreased appetite or anorexia. Lead poisoning affects multiple organ systems, including the gastrointestinal tract, leading to symptoms like abdominal pain and gastrointestinal upset. Anorexia is a common manifestation in individuals, including toddlers, with acute lead poisoning due to these gastrointestinal symptoms.

C. Jaundice: Jaundice is not a typical finding in acute lead poisoning. Jaundice typically occurs when there is an accumulation of bilirubin in the blood, which can be caused by liver dysfunction or obstruction of the bile ducts. Lead poisoning primarily affects the central nervous system, hematopoietic system, and gastrointestinal system rather than the liver.

D. Diarrhea: While gastrointestinal symptoms such as abdominal pain, nausea, and vomiting can occur in acute lead poisoning, diarrhea is not a characteristic symptom. Lead poisoning can cause constipation rather than diarrhea due to its effects on the gastrointestinal tract, such as slowing peristalsis.

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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 on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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