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 A

Explanation

A. Assist the client to the correct room: This option addresses the immediate safety concern by guiding the client back to their own room, reducing distress for both the client and the other resident. It promotes dignity and minimizes the risk of agitation or further disruptive behavior.

B. Place the client in restraints: Restraints should only be used as a last resort for safety when all other measures have been exhausted and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful to individuals with Alzheimer's disease and should not be used unless absolutely necessary.

C. Reorient the client to time and place: Reorientation may not be effective for clients with advanced Alzheimer's disease, as their cognitive impairments may limit their ability to understand or retain this information. Additionally, reorientation may not address the immediate safety concern posed by the client's behavior.

D. Move the client to a room at the end of the hall: While this option may be considered in some situations to minimize disruption to other residents, it does not address the underlying issue of the client's confusion or wandering behavior. Additionally, moving the client may cause further distress and confusion.

A. "I want to learn how to empty my child's urinary catheter bag." B. "I'm glad that my child's ostomy is only temporary. C. "I’m glad my child will have normal bowel movements now." D. "I want to learn how to use my child's feeding tube as soon as possible"

Correct Answer is B

Explanation

A. "I want to learn how to empty my child's urinary catheter bag."

This statement indicates a misunderstanding of the child's condition. Hirschsprung disease affects the large intestine and does not typically require a urinary catheter. Therefore, this statement does not demonstrate an understanding of the teaching.

B. "I'm glad that my child's ostomy is only temporary."

This statement indicates an understanding of the teaching. Hirschsprung disease can sometimes require the creation of a temporary ostomy as part of the surgical treatment. Recognizing that the ostomy is temporary reflects comprehension of the planned treatment.

C. "I’m glad my child will have normal bowel movements now."

This statement reflects a misunderstanding of the surgical treatment for Hirschsprung disease. While surgery can improve bowel function, it may not result in completely normal bowel movements. Therefore, this statement does not demonstrate an accurate understanding of the teaching.

D. "I want to learn how to use my child's feeding tube as soon as possible."

Hirschsprung disease and its surgical treatment typically do not involve the use of a feeding tube. Therefore, this statement indicates a misunderstanding of the child's condition and the planned treatment.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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