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Which of the following interventions should the nurse plan to use to reduce client focus on delusional thinking?
- A. Confronting the delusion
- B. Focusing on feelings suggested by the delusion
- C. Refuting the delusion with logic
- D. Exploring reasons the client has the delusion
Correct Answer: B
Rationale: The correct answer is B: Focusing on feelings suggested by the delusion. By addressing the underlying emotions associated with the delusion, the nurse can help the client process and cope with their feelings, ultimately reducing the intensity of the delusional thinking. Confronting the delusion (A) may lead to resistance and escalation. Refuting the delusion with logic (C) can be ineffective as it may reinforce the client's belief. Exploring reasons for the delusion (D) may not directly address the client's focus on delusional thinking.
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What is not the primary evidence-based approach to managing oppositional behaviour in children?
- A. Cognitive-behavioural intervention
- B. Psychosocial intervention
- C. Pharmacological intervention
- D. Family therapy
Correct Answer: C
Rationale: Pharmacological intervention is not a primary approach for oppositional behavior; psychosocial interventions like parent training are first-line.
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 person diagnosed with a serious mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority?
- A. Find supported employment
- B. Develop a trusting relationship
- C. Administer prescribed medication
- D. Teach appropriate health care practices
Correct Answer: B
Rationale: Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.
The nurse is caring for a client who is being treated for comorbid eating or affective disorder. For which medication would the nurse expect to prepare a client teaching plan?
- A. Fluoxetine (Prozac).
- B. Diazepam (Valium).
- C. Lorazepam (Ativan).
- D. Lithium.
Correct Answer: A
Rationale: The correct answer is A: Fluoxetine (Prozac). Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat eating disorders and affective disorders like depression. The nurse would prepare a client teaching plan for fluoxetine to educate the client on its mechanism of action, potential side effects, proper dosing, and the importance of compliance. Diazepam and lorazepam are benzodiazepines used for anxiety and not typically indicated for eating or affective disorders. Lithium is primarily used for bipolar disorder and not specifically for eating or affective disorders.
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.