Forty-eight hours after starting haloperidol, the client is observed standing by the nurse’s station with his neck arched sharply backward. The nurse recognizes that the client:

Choice A Reason: Teach the client to avoid “I” statements related to the expression of feelings

Teaching a client to avoid “I” statements is not a recommended intervention. In fact, “I” statements are often encouraged in therapeutic settings because they help individuals express their feelings without blaming others. For example, saying “I feel angry when…” helps to communicate emotions constructively and can be a part of anger management strategies.

Choice B Reason: Tell the client to stop using a loud angry voice

While it might seem logical to ask a client to stop using a loud, angry voice, this approach can be counterproductive. It may escalate the situation by making the client feel unheard or invalidated. Instead, it is more effective to acknowledge the client’s feelings and then guide them towards expressing their anger in a more appropriate manner.

Choice C Reason: Use therapeutic touch to convey empathy

Therapeutic touch involves using physical touch to convey empathy and support. However, its effectiveness can vary depending on the client’s comfort with touch and cultural background. Some clients may find touch comforting, while others may find it intrusive or uncomfortable. Therefore, it is important to assess the client’s preferences and obtain consent before using therapeutic touch.

Choice D Reason: Clearly explain the consequences of the behavior

This is the correct answer. Clearly explaining the consequences of inappropriate behavior helps set boundaries and provides the client with an understanding of the impact of their actions. It is a crucial part of behavior management and helps the client learn appropriate ways to express their emotions. This approach is aligned with cognitive-behavioral strategies that focus on understanding the relationship between thoughts, feelings, and behaviors.

Choice A Reason:

Manifestation of dyslexia.

Dyslexia is a learning disorder characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. It is not typically associated with the creation of new words or phrases, which is what the term ‘mazurka’ represents in this context. Therefore, the client’s use of ‘mazurka’ is not a manifestation of dyslexia.

Choice B Reason:

Example of loose associations.

Loose associations refer to a thought disorder where ideas are presented with little or no logical connection between them. While this is a common symptom in schizophrenia, it does not specifically involve the creation of new words. The term ‘mazurka’ in this context does not illustrate a lack of logical connection between ideas but rather the invention of a new term.

Choice C Reason:

Neologism.

Neologism refers to the creation of new words or phrases that are often only understood by the person who created them. This is a common symptom in schizophrenia, where individuals may invent words that have meaning only to them. The client’s use of ‘mazurka’ fits this definition, as it is a newly created word that likely holds specific meaning for the client.

Choice D Reason:

Flight of ideas.

Flight of ideas is a symptom characterized by rapid and continuous speech with abrupt changes from topic to topic, usually based on understandable associations, distracting stimuli, or plays on words. This symptom is more commonly associated with manic episodes rather than schizophrenia. The use of ‘mazurka’ does not indicate rapid topic changes but rather the creation of a new word.