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A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?
- A. Encourage the client to explore the delusions in depth.
- B. Tell the client that the delusions are not real.
- C. Explore the underlying meaning of the delusions.
- D. Distract the client from the delusions and focus on reality.
Correct Answer: D
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.
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A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?
- A. Encourage the client to avoid caffeine.
- B. Suggest the client take up a new hobby.
- C. Teach the client deep breathing exercises.
- D. Refer the client to group therapy.
Correct Answer: C
Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?
- A. 'I'll leave your tray here. I am available if you need anything else.'
- B. 'You're not being poisoned. Why do you think someone is trying to poison you?'
- C. 'No one on this unit has ever died from poisoning. You're safe here.'
- D. 'I will talk to your healthcare provider about the possibility of changing your diet.'
Correct Answer: A
Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.
A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self-harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?
- A. Assure the client that all food served in the hospital is safe to eat.
- B. Tell the client that irrational thinking is a symptom of schizophrenia.
- C. Obtain an order for a tube feeding for the client.
- D. Provide the client with food in unopened containers.
Correct Answer: D
Rationale: The correct intervention is to provide the client with food in unopened containers. This approach can help alleviate the client's fear of poisoning and encourage eating. Choice A may not address the client's specific fear and may be perceived as dismissive. Choice B, while providing information about symptoms of schizophrenia, does not address the immediate issue of the client's refusal to eat due to the fear of poisoning. Choice C of obtaining an order for tube feeding is premature and invasive before exploring less restrictive options.
An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?
- A. The client is manic and may need a sleeping pill
- B. The client is experiencing a medication interaction and should go to the ED
- C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
- D. The client is overcome by grief and probably needs an antidepressant
Correct Answer: C
Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.
What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?
- A. Allow the client to continue washing her hands.
- B. Set limits on the time spent washing her hands.
- C. Encourage the client to wash her hands less frequently.
- D. Assist the client in finding alternative ways to reduce anxiety.
Correct Answer: D
Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.