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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Speaking in short phrases or sentences: This indicates severe dyspnea and increased work of breathing, suggesting the client may not be able to maintain adequate ventilation and oxygenation. It is a sign of respiratory distress and requires immediate intervention.
B. Distant heart sounds: While this may be present in COPD due to hyperinflation of the lungs, it is not immediately life-threatening and does not require urgent action compared to severe dyspnea.
C. Diminished lung sounds: This is common in COPD due to air trapping and hyperinflation but does not always indicate acute deterioration unless accompanied by other distress signs.
D. Pursed-lip breathing: This is actually a beneficial compensatory mechanism that helps keep airways open longer to improve carbon dioxide elimination and is not a sign of acute danger.
Correct Answer is C
Explanation
A. Depressive characteristics of schizophrenia: While some atypical antipsychotics may have mood-stabilizing effects, paliperidone is not primarily indicated for treating depressive symptoms. Antidepressants are more effective for depressive features rather than antipsychotic agents.
B. Negative symptoms of schizophrenia only: Paliperidone helps address negative symptoms such as social withdrawal and blunted affect, but it is not limited to these alone. Its mechanism of action also targets positive symptoms, making this option incomplete.
C. Both positive and negative symptoms of schizophrenia: Paliperidone, an atypical antipsychotic, blocks dopamine D2 receptors and serotonin 5-HT2A receptors. This dual action makes it effective for reducing hallucinations and delusions (positive symptoms) as well as improving motivation and affect (negative symptoms).
D. Low serotonin levels: Paliperidone does act on serotonin receptors, but it does not treat “low serotonin levels” as a standalone condition. Instead, the benefit is its balanced effect on both dopamine and serotonin pathways, reducing positive and negative symptoms in schizophrenia.
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