The nurse is caring for a client with schizophrenia. Which of the following would be a priority nursing goal for this client’s care?
Promote interaction with others.
Encourage participation in group therapy activities.
Decrease their anxiety and increase trust.
Improve their relationship with their parents.
The Correct Answer is C
Choice A Reason:
Promote interaction with others.
While promoting interaction with others is important for clients with schizophrenia, it is not the primary priority. Social interaction can help improve social skills and reduce isolation, but it should come after establishing a sense of safety and trust. Clients with schizophrenia often experience significant anxiety and mistrust, which need to be addressed first to create a stable foundation for further therapeutic interventions.
Choice B Reason:
Encourage participation in group therapy activities.
Encouraging participation in group therapy activities is beneficial for clients with schizophrenia as it can provide support and help them develop social skills. However, similar to promoting interaction with others, this goal is secondary to decreasing anxiety and building trust. Clients need to feel safe and trust their caregivers before they can effectively engage in group therapy.
Choice C Reason:
Decrease their anxiety and increase trust.
This is the correct response. Decreasing anxiety and increasing trust are fundamental goals in the care of clients with schizophrenia. High levels of anxiety and mistrust can exacerbate symptoms and hinder the effectiveness of other therapeutic interventions. Establishing a trusting relationship and reducing anxiety can create a more stable and supportive environment, which is essential for the client’s overall well-being and progress.
Choice D Reason:
Improve their relationship with their parents.
Improving the client’s relationship with their parents can be an important aspect of their overall treatment plan, especially if family dynamics contribute to their condition. However, this goal is not the immediate priority. Addressing the client’s anxiety and building trust should come first, as these are critical for the client’s stability and ability to engage in family therapy effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is B
Explanation
Choice A Reason:
Somatic.
Somatic delusions involve a false belief that there is something physically wrong with one’s body, such as having a serious illness or a physical defect. In this scenario, the client’s belief that the food is poisoned does not relate to their own body but rather to an external threat, making somatic delusions an incorrect classification.
Choice B Reason:
Persecutory.
This is the correct response. Persecutory delusions, also known as paranoid delusions, involve the belief that one is being targeted, harassed, or conspired against. The client’s statement that the staff is poisoning the food reflects a belief that they are being harmed or targeted, which is characteristic of persecutory delusions. These types of delusions are the most common in schizophrenia and often involve themes of being persecuted or plotted against.
Choice C Reason:
Erotomanic.
Erotomanic delusions involve the false belief that another person, often someone of higher status, is in love with the individual. This type of delusion is not relevant to the client’s statement about the food being poisoned, as it does not involve any romantic or affectionate themes.
Choice D Reason:
Grandiose.
Grandiose delusions involve an inflated sense of one’s own importance, power, knowledge, or identity. The client’s belief about the food being poisoned does not reflect an exaggerated sense of self-importance or power, making grandiose delusions an incorrect classification for this scenario.
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