Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?
Ask open-ended questions.
Focus on what is happening in the here and now.
Assume knowledge of what is meant when the client talks about “they.”
Limit contact to one or two short interactions daily.
The Correct Answer is B
Choice A Reason:
Ask open-ended questions.
While asking open-ended questions can be useful in many therapeutic settings, it may not be the best approach when dealing with delusional clients. Open-ended questions can sometimes lead to more elaborate delusional thinking and may not help in grounding the client in reality. Instead, focusing on the present moment and concrete reality can be more effective in managing delusions.
Choice B Reason:
Focus on what is happening in the here and now.
This is the correct response. Focusing on the present moment helps to ground the client in reality and can reduce the intensity of delusional thoughts. By directing the client’s attention to their immediate environment and current activities, the nurse can help the client stay connected to reality and reduce the impact of their delusions.
Choice C Reason:
Assume knowledge of what is meant when the client talks about “they.”
Assuming knowledge of what the client means when they refer to “they” can reinforce delusional thinking. It is important for the nurse to clarify and understand the client’s perspective without validating the delusion. This approach helps maintain a therapeutic relationship while not reinforcing false beliefs.
Choice D Reason:
Limit contact to one or two short interactions daily.
Limiting contact to one or two short interactions daily is not an effective strategy for managing delusions. Clients with delusions often need consistent and supportive interactions to help them stay grounded in reality. Frequent, brief interactions can provide the necessary support and reassurance without overwhelming the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Uses relaxation techniques for stress reduction.
Using relaxation techniques for stress reduction is generally considered safe and beneficial. Techniques such as deep breathing, meditation, and progressive muscle relaxation can help reduce stress and anxiety without significant risks. Therefore, this information does not require immediate investigation.
Choice B Reason:
Expresses an interest in yoga to improve flexibility.
Expressing an interest in yoga to improve flexibility is also generally safe and beneficial. Yoga can enhance physical flexibility, strength, and mental well-being. Unless the client has specific health conditions that might be affected by certain yoga poses, this information does not require immediate investigation.
Choice C Reason:
Has tried acupressure for pain relief several years ago.
Trying acupressure for pain relief several years ago is not typically a cause for concern. Acupressure is a non-invasive therapy that can help alleviate pain and promote relaxation. Since it was used in the past and not currently, it does not require immediate investigation.
Choice D Reason:
Has been using herbal supplements without consulting a healthcare provider.
This is the correct response. Using herbal supplements without consulting a healthcare provider can be risky because some supplements can interact with prescribed medications or have side effects. It is crucial for the nurse to investigate this information immediately to ensure the client’s safety and prevent potential adverse effects.
Correct Answer is D
Explanation
Choice A Reason:
Pseudo-Parkinsonian side effects, also known as drug-induced parkinsonism, can occur with the use of antipsychotic medications like haloperidol. These side effects include symptoms such as rigidity, bradykinesia, tremor, and postural instability. However, the description of the client’s neck arched sharply backward is more indicative of an acute dystonic reaction rather than pseudo-Parkinsonian side effects. Pseudo-Parkinsonian symptoms typically develop more gradually and do not present with such dramatic posturing.
Choice B Reason:
While some side effects of haloperidol can be temporary and may disappear after several days, the acute dystonic reaction described in the scenario requires immediate intervention. Acute dystonic reactions are characterized by sudden, severe muscle contractions that can be painful and potentially dangerous if they involve the airway. Therefore, it is crucial to address this reaction promptly rather than waiting for it to resolve on its own.
Choice C Reason:
Increasing the dosage of haloperidol in response to the described symptoms would likely exacerbate the situation. The client’s symptoms are not indicative of worsening psychotic behavior but rather an adverse reaction to the medication. Increasing the dosage could lead to more severe side effects and complications. The appropriate response is to treat the acute dystonic reaction and reassess the medication regimen.
Choice D Reason:
An acute dystonic reaction is a known side effect of antipsychotic medications like haloperidol. It involves sudden, severe muscle contractions, often affecting the neck, face, and back. This reaction can be distressing and requires immediate treatment with anticholinergic medications such as benztropine or diphenhydramine. Prompt intervention can relieve the symptoms and prevent further complications.
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