The nurse is creating a plan of care for a client with schizophrenia. Which nursing intervention will the nurse perform first when caring for this client?

Maintain reality through frequent contact

Assess community support systems

Encourage client to participate in the treatment milieu

Observe for signs of fear or agitation

Answer and Explanation

The Correct Answer is D

A. Maintain reality through frequent contact: Helping the client stay oriented and distinguishing delusions from reality is important in schizophrenia care. However, this can only be effectively implemented after ensuring the client is safe and not experiencing acute agitation that could escalate into harm to self or others.

B. Assess community support systems: Evaluating long-term support systems is a vital part of discharge planning and continuity of care. While important, it is not the immediate priority during initial client assessment, especially if the client is showing signs of acute psychosis or agitation.

C. Encourage client to participate in the treatment milieu: Social engagement in the therapeutic environment helps reduce isolation and promotes recovery. However, this intervention is only effective after the nurse ensures that the client is calm, stable, and safe to interact with others.

D. Observe for signs of fear or agitation: This is the priority because safety and stabilization are the first concerns in schizophrenia care. Fear or agitation can quickly escalate to aggression or self-harm, so early observation allows the nurse to intervene promptly and prevent harm while planning further care.

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Correct Answer is A

Explanation

A. "I can use a regular toothbrush but brush gently.": Clients receiving chemotherapy and radiation often develop thrombocytopenia or mucositis. A regular toothbrush can cause gum trauma and bleeding. The client should use a soft-bristled toothbrush or foam swabs to reduce oral injury and infection risk.

B. "I should balance my activities throughout the day to allow for rest periods.": Fatigue is a major side effect of cancer treatment, and conserving energy through activity pacing helps maintain independence while preventing exhaustion.

C. "I should include frequent small meals throughout the day.": Nausea, anorexia, and altered taste are common treatment side effects. Smaller meals are easier to tolerate and help maintain adequate nutrition and caloric intake.

D. "I should use an electric razor.": Due to potential thrombocytopenia and bleeding risk, electric razors are recommended instead of blades to minimize cuts and reduce complications during treatment.

A. Outcomes that focus on change in behavior B. Outcomes that focus on satisfaction with daily life C. Outcomes that focus on increased medication adherence D. Outcomes that focus on the client's perception of others

Correct Answer is A

Explanation

A. Outcomes that focus on change in behavior: Therapy for personality disorders emphasizes gradual behavioral change, such as improved coping skills, communication, and interpersonal interactions. These measurable and realistic goals are central to treatment.

B. Outcomes that focus on satisfaction with daily life: While improved life satisfaction may occur over time, it is not a primary or realistic early outcome because personality disorders involve deeply ingrained patterns that change slowly.

C. Outcomes that focus on increased medication adherence: Medications may help with symptom management, but they are not the core treatment for personality disorders. The focus is on psychotherapy and behavioral modification.

D. Outcomes that focus on the client's perception of others: Altering deep-seated perceptions and beliefs is difficult and not a realistic short-term outcome. Behavioral adjustments are more achievable than changing ingrained cognitive patterns.

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The nurse is creating a plan of care for a client with schizophrenia. Which nursing intervention will the nurse perform first when caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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