A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?
Place the client in seclusion if visual hallucinations are present.
Limit the number of questions asked during assessments.
Use frequent touch to provide client support.
Directly tell the client that delusions are not real.
The Correct Answer is B
Choice A reason:
Placing the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention. Seclusion should only be used when the client poses an immediate threat to themselves or others and less restrictive measures have failed. It is important to use the least restrictive interventions to manage symptoms.
Choice B reason:
Limiting the number of questions asked during assessments can help reduce the client’s anxiety and prevent overwhelming them. Clients with schizophrenia may have difficulty processing information and may become more paranoid or distressed with too many questions. This approach helps create a more supportive and manageable environment for the client.
Choice C reason:
Using frequent touch to provide client support is not recommended for clients with paranoid delusions. Physical touch may be misinterpreted as a threat or invasion of personal space, exacerbating the client’s paranoia and anxiety. It is important to respect the client’s boundaries and use other forms of support.
Choice D reason:
Directly telling the client that delusions are not real can be confrontational and may increase the client’s distress. Instead, the nurse should acknowledge the client’s feelings and provide reassurance without directly challenging their beliefs. This approach helps maintain a therapeutic relationship and supports the client’s emotional well-being.
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View Related questions
Correct Answer is D
Explanation
Choice A reason:
“A relapse plan describes how you use coping strategies for living in the community.” While this is partially true, it does not fully capture the purpose of a relapse plan. A relapse plan is more comprehensive and includes recognizing early warning signs and taking specific actions to prevent a full relapse.
Choice B reason:
“A relapse plan addresses your living, housing, and working needs.” This statement is not accurate. A relapse plan focuses on managing symptoms and preventing relapse rather than addressing broader social needs like housing and employment.
Choice C reason:
“A relapse plan explains how you can be hospitalized if needed.” While hospitalization may be part of a relapse plan, the primary focus is on recognizing early symptoms and taking steps to manage them before hospitalization becomes necessary.
Choice D reason:
“A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse.” This statement accurately reflects the purpose of a relapse plan. It emphasizes the importance of early recognition and proactive management of symptoms to support the client’s recovery.
Correct Answer is A
Explanation
Choice A reason:
Countertransference occurs when a healthcare provider projects their own feelings and experiences onto the client. In this case, the nurse is responding to the client as if they were their grandparent, which indicates that the nurse’s personal feelings are influencing their professional relationship.
Choice B reason:
Empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing, it does not involve projecting personal relationships onto the client.
Choice C reason:
Transference occurs when a client projects feelings about important figures in their life onto the healthcare provider. This is the opposite of countertransference, where the provider projects their feelings onto the client.
Choice D reason:
Modeling involves demonstrating behaviors for others to imitate. It does not describe the emotional reaction of projecting personal feelings onto a client.