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?

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.

Incorrect:

A. Developing autonomy:

Rationale: Developing autonomy typically involves a toddler's exploration of their environment and assertion of independence. While seeking comfort in familiar behaviors like thumb-sucking can be a part of autonomy development, the behavior described in the scenario is more indicative of regression, which involves returning to earlier, more infantile behaviors rather than progressing towards independence.

B. Regression:

Rationale: Regression refers to reverting to behaviors characteristic of an earlier stage of development. In this scenario, the toddler's behavior of sitting quietly in the corner of the crib and sucking her thumb, as well as turning away from the nurse, suggests a regression to earlier comforting behaviors that are typical of younger infants. This regression may be a response to the stress and anxiety of being hospitalized and separated from the mother, seeking comfort in familiar behaviors.

C. Resentment toward the mother:

Rationale: There is no evidence in the scenario to suggest resentment toward the mother. The toddler's behavior of seeking comfort in thumb-sucking and turning away from the nurse is more indicative of distress or regression in response to the hospitalization and separation from the mother rather than directed resentment toward her.

D. An anxiety reaction:

Rationale: The toddler's behavior of sitting quietly in the corner of the crib, sucking her thumb, and turning away from the nurse suggests a response to stress or anxiety rather than an anxiety reaction per se. While anxiety may be a component of the toddler's emotional state, the behavior aligns more closely with regression as a coping mechanism in response to the stressors of hospitalization and separation from the mother.