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A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
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A client experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the client to employ when the voices are troublesome?
- A. Take additional antipsychotic medication
- B. Lie down in bed and try to sleep
- C. Sing or whistle to compete with the voices
- D. Eat a large portion of chocolate
Correct Answer: C
Rationale: The correct answer is C: Sing or whistle to compete with the voices. This technique is effective as it can help distract the client from the intrusive auditory hallucinations. By engaging in singing or whistling, the client can shift their focus away from the voices, making them less bothersome. This method can also empower the client by giving them a sense of control over the situation.
Other choices are incorrect:
A: Taking additional antipsychotic medication may not be necessary in this situation and should be prescribed by a healthcare provider.
B: Lying down and trying to sleep may not address the immediate distress caused by the hallucinations.
D: Eating a large portion of chocolate is not a valid behavioral technique for managing auditory hallucinations.
A patient with schizophrenia has been stabilized in the Crisis Center and is about to be discharged. He will be living with his family, but the family knows nothing about the patient's illness, its treatment, or the role they can play in his recovery. Which activity would be most beneficial for the family to attend?
- A. Psychoanalytic group
- B. Psychoeducational group
- C. Individual counseling
- D. Family therapy
Correct Answer: B
Rationale: The correct answer is B: Psychoeducational group. This option is most beneficial as it provides education and information to the family about the patient's illness, treatment options, and ways they can support his recovery. It helps them understand the challenges the patient faces and equips them with practical strategies to assist in his recovery process.
A: Psychoanalytic group focuses on exploring unconscious patterns of behavior and may not provide the necessary education and tools for the family to support the patient effectively.
C: Individual counseling is focused on the patient and may not involve the family members in understanding the illness and their role in the patient's recovery.
D: Family therapy involves the whole family in therapy sessions, but may not specifically focus on educating them about schizophrenia and its treatment, which is crucial for their support.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. appropriately express angry feelings.
- B. verbalize two positive things about self.
- C. verbalize the importance of eating a balanced diet.
- D. identify two alternative methods of coping with loneliness and isolation.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the nursing diagnosis of ineffective coping related to feelings of loneliness and isolation. By identifying two alternative methods of coping, the patient can develop healthier strategies to manage these emotions instead of resorting to overeating and vomiting. This outcome promotes long-term behavioral change and helps the patient build resilience.
Choice A is incorrect because expressing angry feelings may not necessarily address the underlying issues of loneliness and isolation. Choice B is incorrect as verbalizing positive things about oneself may be beneficial but does not directly address coping mechanisms for loneliness and isolation. Choice C is also incorrect because understanding the importance of a balanced diet does not directly address coping strategies for managing emotions like loneliness and isolation.
People who experience psychotic disorders lose:
- A. The will to continue
- B. Contact with reality
- C. The ability to comply with treatment
- D. Contact with intellectual functions
Correct Answer: B
Rationale: Certainly! The correct answer is B: People who experience psychotic disorders lose contact with reality. Psychotic disorders involve a disconnection from reality, leading to hallucinations, delusions, and impaired thinking. This loss of contact with reality is a hallmark of psychotic disorders.
As for the other choices:
A: The will to continue - While individuals with psychotic disorders may struggle with motivation, this is not the primary feature of psychotic disorders.
C: The ability to comply with treatment - While compliance with treatment may be challenging, it is not the core aspect of psychotic disorders.
D: Contact with intellectual functions - While psychotic disorders can impact cognitive abilities, the defining characteristic is the loss of contact with reality rather than intellectual functions.
A client who has been diagnosed as having bulimia nervosa is hospitalized for treatment of electrolyte imbalance. Just before lunch is finished, the client leaves the table and walks quickly in the direction of the bathroom. The nurse should say:
- A. No one is allowed to leave the dining room during meals.'
- B. I must accompany you when you go to the bathroom.'
- C. I think I understand your plan, and I cannot permit you to carry it out.'
- D. Wouldn't it be preferable to exercise rather than vomit?'
Correct Answer: B
Rationale: The correct answer is B because accompanying the client to the bathroom is essential to prevent purging behavior associated with bulimia nervosa. By doing so, the nurse can provide support, monitor the client, and intervene if necessary to ensure the client's safety. Choice A is incorrect as it may come across as punitive and restrictive. Choice C is incorrect as it may escalate the situation and lead to confrontation. Choice D is incorrect as it suggests an alternative behavior without addressing the immediate concern of potential purging. Accompanying the client to the bathroom is the most appropriate and therapeutic response in this situation.