A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?
Use touch to calm the client during periods of anxiety
Check the clients mouth after the client takes medication
Rotate the staff assignments for this client
Assign an assistive personnel to feed the client at meat times
The Correct Answer is B
A. Use touch to calm the client during periods of anxiety:
Individuals with paranoid schizophrenia may have heightened sensitivity to touch, and it can potentially exacerbate their anxiety or paranoia. This intervention may not be appropriate as it could escalate the client's distress.
B. Check the client's mouth after the client takes medication:
This is the best choice. People with paranoid schizophrenia may be prone to hoarding or pocketing medications. Checking the client's mouth ensures that the medication has been swallowed, promoting medication adherence and preventing potential harm.
C. Rotate the staff assignments for this client:
Consistency in caregivers is generally preferred for clients with schizophrenia to build trust and a therapeutic relationship. Constantly changing staff assignments can lead to increased anxiety and mistrust.
D. Assign an assistive personnel to feed the client at meal times:
While assistance with feeding may be needed, assigning an assistive personnel without direct supervision for a client with paranoid schizophrenia may not be the best approach. It's important to ensure the client's safety and monitor their behavior during meals.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dry mouth and urinary retention: These symptoms are not typically associated with the side effects of clozapine. Dry mouth is a common side effect of many antipsychotic medications, but urinary retention is not a typical side effect of clozapine.
B. Akinesia and insomnia: Akinesia (lack of movement) is not a common side effect of clozapine. Insomnia can occur with various antipsychotic medications but does not typically warrant immediate intervention unless severe or persistent.
C. Sore throat, fever, and malaise: These symptoms can indicate a potentially serious side effect known as agranulocytosis, which is a significant reduction in white blood cell count. Clozapine is associated with an increased risk of agranulocytosis. If a client experiences symptoms such as sore throat, fever, or malaise, it may indicate a severe drop in white blood cell count, and immediate medical attention is necessary.
D. Akathisia and hypersalivation: Akathisia (restlessness) is a known side effect of antipsychotic medications, but it is not typically associated with immediate severe medical risks. Hypersalivation is a common side effect but does not usually require immediate intervention unless severe.
Correct Answer is B
Explanation
A. Generalized anxiety disorder and a nursing diagnosis of fear: Generalized anxiety disorder typically involves chronic, excessive worrying and anxiety that is not limited to specific situations or triggers. The sudden and intense symptoms described in the scenario, such as lightheadedness, tremulousness, diaphoresis, tachycardia, and dyspnea, are more indicative of a panic attack rather than generalized anxiety. The nursing diagnosis of fear may not fully capture the acute and intense nature of panic symptoms.
B. Panic disorder and a nursing diagnosis of panic anxiety: This is the correct answer. Panic disorder is characterized by recurrent, unexpected panic attacks, which align with the sudden onset of symptoms described in the scenario. The nursing diagnosis of panic anxiety is appropriate as it addresses the acute distress associated with panic attacks.
C. Pain disorder and a nursing diagnosis of altered role performance: There is no indication of pain being the primary issue in this scenario. The symptoms are more indicative of a panic attack rather than a pain disorder. Additionally, altered role performance is not a priority nursing diagnosis when addressing the acute symptoms of a panic attack.
D. Altered sensory perception and a nursing diagnosis of panic disorder: Altered sensory perception is not the primary issue in this scenario, and it does not specifically address the sudden and intense symptoms described. The focus should be on the panic symptoms and the associated distress, leading to the nursing diagnosis of panic anxiety.
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