A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Ask the client, “What are the voices saying to you?”

Give the client a PRN dose of benztropine.

Call and report the behavior to the physician.

Tell the client, “Well, I see you’re distracted right now. We’ll talk more later.”

Answer and Explanation

The Correct Answer is A

The correct answer is a.

Choice A Reason:

The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:

The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.

Choice C Reason:

The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.

Choice D Reason:

The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.

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Correct Answer is C

Explanation

Choice A Reason:

Administer the medication with food.

Administering clonazepam with food can help reduce gastrointestinal discomfort, but it is not the most critical consideration. While it is beneficial to minimize potential side effects like nausea, it does not address the primary safety concerns associated with clonazepam use.

Choice B Reason:

Administer the medication to the client at night to avoid daytime sedation.

Administering clonazepam at night can help avoid daytime sedation, which is a common side effect of benzodiazepines. However, this is not the most critical safety concern. While managing sedation is important, it does not address the potential for more serious interactions and risks.

Choice C Reason:

Encourage the client to avoid drinking alcohol when taking this medication.

This is the correct response. Alcohol can significantly increase the sedative effects of clonazepam, leading to dangerous levels of sedation, respiratory depression, and even death. It is crucial to educate clients about the risks of combining alcohol with benzodiazepines to prevent potentially life-threatening interactions.

Choice D Reason:

Assess for history of smoking.

While assessing for a history of smoking is part of a comprehensive health assessment, it is not the most critical consideration when administering clonazepam. Smoking does not have the same immediate and severe interaction risks with clonazepam as alcohol does.

A. Word salad. B. Loose association. C. Clang association. D. Ideas of reference.

Correct Answer is C

Explanation

Choice A Reason:

Word salad.

Word salad refers to a jumble of words and phrases that lack logical coherence, often seen in severe cases of schizophrenia. The speech is typically incomprehensible and does not follow any recognizable pattern. In this case, the client’s response, while unusual, follows a pattern based on sound rather than meaning, which does not fit the definition of word salad.

Choice B Reason:

Loose association.

Loose association involves a series of thoughts that are only loosely connected to each other. This is a common symptom in schizophrenia, where the person’s thoughts may drift from one topic to another with little logical connection. However, the client’s response in this scenario is more structured and based on rhyming, which is characteristic of clang associations rather than loose associations.

Choice C Reason:

Clang association.

Clang association is a type of thought disorder where the person’s speech is governed by the sound of words rather than their meaning. This often results in rhyming or punning speech. The client’s response, “A match is a catch. A catch is a batch. The batch started to hatch,” is a clear example of clang association because the words are linked by their similar sounds rather than their meanings.

Choice D Reason:

Ideas of reference.

Ideas of reference involve the belief that ordinary events, objects, or behaviors of others have particular and unusual significance specifically for the person. This is often seen in paranoid schizophrenia. The client’s response does not indicate that they believe the words have special personal significance; instead, it shows a pattern of rhyming, which is more indicative of clang association.

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A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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