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The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take?
- A. Tell the client that the hospital is a safe place.
- B. Urge the client to reveal more information.
- C. Focus on developing a trusting relationship with the client.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Building trust is critical for clients with paranoia, who may be suspicious and guarded. A trusting relationship encourages engagement and cooperation, making it the priority over reassurance, urging disclosure, or socialization.
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The nurse is planning interventions for counseling a maternal client who has been newly diagnosed with sickle cell anemia. Which would be the most important psychosocial intervention at this time?
- A. Help the client identify her concerns.
- B. Avoid discussing the details of the disease.
- C. Allow the client to be alone if she is crying.
- D. Encourage family and friends to visit the client frequently.
Correct Answer: A
Rationale: One of the most important nursing roles is providing emotional support to the client and family during the counseling process. Option 2, like option 4, is nontherapeutic. Option 3 is only appropriate if the client requests to be alone; if this is not requested, the nurse is abandoning the client in a time of need. Option 4 overwhelms the client with information while she is trying to cope with the news of the disease.
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
- A. residual schizophrenia
- B. paranoid schizophrenia
- C. catatonic schizophrenia
- D. disorganized schizophrenia
- E. undifferentiated schizophrenia
Correct Answer: D
Rationale: Disorganized schizophrenia is characterized by social withdrawal, inappropriate affect, grimacing, and impaired daily functioning. Residual (A) involves milder symptoms, paranoid (B) involves delusions, catatonic (C) involves motor issues, and undifferentiated (E) lacks specific features.
The nurse provides care for four clients who require teaching about their medical conditions. The nurse assesses that which client is the most ready to learn?
- A. A client who woke up from a nap recently, just ate a snack, and is sitting up in bed.
- B. A client who was just informed of a cancer diagnosis by the health care provider.
- C. A client recovering from a stroke who has returned from physical therapy.
- D. A client who received pain medication 5 minutes ago for relief of discomfort.
Correct Answer: A
Rationale: A client who is rested, nourished, and alert (after a nap and snack, sitting up) is in an optimal state for learning. Recent diagnosis, fatigue from therapy, or recent pain medication may impair readiness to learn.
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
- A. residual schizophrenia
- B. paranoid schizophrenia
- C. catatonic schizophrenia
- D. disorganized schizophrenia
- E. undifferentiated schizophrenia
Correct Answer: D
Rationale: Disorganized schizophrenia is characterized by inappropriate affect, social withdrawal, grimacing, and impaired daily functioning.
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.