On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, "I am the son of God." Based on this statement, which intervention should the nurse include in this client's plan of care?

Confront the client's delusion as not consistent with reality.

Schedule activity therapy twice weekly.

Ensure the client's environment is safe.

Lead the client by the arm to the seclusion room.

Answer and Explanation

The Correct Answer is C

Choice A reason: Confronting delusions directly can increase agitation and disrupt therapeutic rapport in schizophrenia. Ensuring a safe environment addresses potential risks from delusional behavior without challenging beliefs, aligning with psychiatric nursing principles for managing psychosis, making this incorrect for the care plan.

Choice B reason: Activity therapy supports socialization but does not address the immediate safety needs posed by the client’s delusion. Ensuring a safe environment prevents harm related to grandiose beliefs, making this intervention secondary and incorrect compared to prioritizing safety in acute schizophrenia management.

Choice C reason: Ensuring a safe environment is critical for a client with schizophrenia expressing delusions, as grandiose beliefs may lead to risky behaviors. This intervention minimizes harm while supporting therapeutic engagement, aligning with safety-first psychiatric care principles, making it the most appropriate care plan inclusion.

Choice D reason: Leading the client to seclusion is overly restrictive and unwarranted based solely on a delusion, which is not inherently dangerous. Ensuring safety through environmental management is less invasive and more therapeutic, making seclusion incorrect for managing this client’s delusional statement.

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Correct Answer is D

Explanation

Choice A reason: Journaling and self-reflection are useful but may overwhelm a depressed client who lacks motivation. Regular nurse-client interaction provides consistent support, fostering trust and engagement, which is more immediate for inpatient care. This intervention is secondary, making it incorrect for demonstrating primary support.

Choice B reason: Animated communication may be inappropriate for depression, where clients often feel withdrawn. Regular interaction with a calm, supportive presence better addresses the client’s need for connection. Animated techniques risk alienating the client, making this incorrect for demonstrating effective support in major depressive disorder.

Choice C reason: Identifying depression symptoms is part of assessment, not ongoing support. Scheduled interactions build therapeutic rapport, directly addressing the client’s emotional needs in depression. Symptom identification is less supportive than consistent presence, making this incorrect for the primary intervention to demonstrate support.

Choice D reason: Scheduling regular interactions demonstrates support by providing consistent, empathetic engagement, countering the isolation of depression. This fosters trust and therapeutic alliance, critical for inpatient psychiatric care, aligning with nursing principles for major depressive disorder management, making it the most effective intervention for support.

A. An adult with schizophrenia who often refuses to take prescribed antipsychotic medications. B. An adolescent who is depressed over not being accepted by peers. C. A hyperactive 4-year-old who has recently been tested for autism. D. An older adult resident of a long-term care facility who sometimes takes other residents' belongings.

Correct Answer is B

Explanation

Choice A reason: An adult with schizophrenia may struggle with role playing due to disorganized thinking or delusions, especially if non-compliant with medications. Adolescents with depression can better engage in role playing to address social issues, making this less suitable and incorrect for therapeutic benefit.

Choice B reason: An adolescent depressed over peer rejection can benefit from role playing to practice social skills and build confidence, directly addressing their emotional concerns. This intervention aligns with psychiatric therapy for adolescent depression, making it the most likely to benefit from this therapeutic approach.

Choice C reason: A hyperactive 4-year-old tested for autism may not have the cognitive or attention capacity for role playing, which requires focus and abstraction. Adolescents with depression are better suited, as they can engage meaningfully, making this incorrect for the therapeutic intervention’s target.

Choice D reason: An older adult taking belongings may have dementia or behavioral issues, making role playing less effective due to cognitive limitations. Adolescents with depression can better process social scenarios, making this incorrect, as role playing is less beneficial for this older adult’s behavior.

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On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, "I am the son of God." Based on this statement, which intervention should the nurse include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the nurse use to demonstrate support of the client?

Correct Answer is D

Explanation

The nurse plans to use role playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

Correct Answer is B

Explanation

A young female client is admitted to the emergency department because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client’s chief concern?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse document?

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. While planning nursing care, which intervention has the highest priority at this time?

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply)