Nokea
All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client?
- A. Observe for signs of fear or agitation
- B. Maintain reality through frequent contact
- C. Encourage to participate in the treatment milieu
- D. Assess community support systems
Correct Answer: A
Rationale: Observing for fear or agitation prioritizes safety, addressing potential escalation before other interventions like reality orientation or social participation.
You may also like to solve these questions
A client who has suspicion has been placed in a room with a roommate. The night nurse reports that this client has been awake for the past 3 nights. The likely explanation for his wakefulness is which of the following?
- A. He is fearful of what his roommate might do to him while he sleeps.
- B. He is a light sleeper and unaccustomed to a roommate.
- C. He is watching for an opportunity to escape.
- D. He is worrying about his family problems.
Correct Answer: A
Rationale: Suspicion in schizophrenia often causes fear of harm from others, like a roommate, making it the most likely reason for wakefulness over other explanations.
One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, 'Goodays I'm supposed to guard the area.' Which of the following responses would be best?
- A. I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice.
- B. The voices are part of your illness, and they will leave in time.
- C. This guarding responsibility can make you tired. You rest for now, and I'll guard a while.
- D. You are just imagining these things. Do not pay any attention to the voices.
Correct Answer: A
Rationale: Acknowledging the client's experience while presenting reality validates their perception without reinforcing the delusion, unlike dismissive or reinforcing responses.
Which of the following attitudes would be best for the nurse when the client who has schizophrenia acts as though the nurse is not trustworthy or that his or her integrity is being questioned?
- A. That the client is correct and the nurse is not trustworthy
- B. That the client wants to insult the nurse
- C. That the client's behavior is a part of the illness
- D. That the nurse's actions have failed
Correct Answer: C
Rationale: Recognizing suspicious behavior as part of schizophrenia avoids personalizing it, maintaining therapeutic objectivity, unlike assuming distrust or failure.
The client with schizophrenia is experiencing delusions. Which of the following is the most appropriate response by the nurse?
- A. I can see you want to be alone. I'll come back another time.
- B. What are you hearing and seeing?
- C. I don't hear or see anyone else, what are you hearing and seeing?
- D. I can tell you are hearing voices but they are not real.
Correct Answer: C
Rationale: Presenting reality while inquiring about the client's experience avoids reinforcing delusions and promotes engagement, unlike dismissing or confronting the delusion directly.
The client with schizophrenia tells the nurse that rats have started to eat his brain. The best response by the nurse would be.
- A. Have you discussed this with your physician?
- B. How could that be possible?
- C. You cannot have rats in your brain.
- D. You look OK to me.
Correct Answer: A
Rationale: Referring to the physician for a new symptom like a delusion prompts potential medication review, unlike defensive, dismissive, or non-therapeutic responses.