The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?
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Solution
Risk for violence toward self or others
Option A: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others.
Options B, C, and D: The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.
A client who has been hospitalized with disorganized type schizophrenia for 8 years can’t complete activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client?
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Solution
“Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month.”
Option C: The client’s disorganized personality and history of hospitalization have affected the ability to perform self-care activities.
Option A: Interventions should be directed at helping the client complete ADLs with the assistance of staff members, who can provide needed structure by helping the client select grooming items and clothing. This goal promotes realistic independence.
Option B: As the client improves and achieves the established goal, the nurse can set new goals that focus on the client completing ADLs with only verbal encouragement and, ultimately, completing them independently.
Option D: The client’s condition doesn’t indicate a need for complete assistance, which would only foster dependence.
The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid:
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Solution
has a more predictable onset of action.
Option A: A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset of tablets is unpredictable.
A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing:
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Solution
ideas of reference.
Option C: Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual.
Option A: A delusion is a false belief.
Option B: Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another.
Option D: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences.
A client with catatonic schizophrenia is mute, can’t perform activities of daily living, and stares out the window for hours. What is the nurse’s first priority?
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Solution
Assist the client with feeding.
Option A: According to Maslow’s hierarchy of needs, the need for food is among the most important.
Options B, C, and D: Other needs, in order of decreasing importance, include hygiene, safety, and a sense of belonging.
A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for hallucinating clients is to:
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Solution
practice saying “Go away” or “Stop” when they hear voices.
Option B: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop.
Option A: Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren’t likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs.
Option C: Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged.
Option D: Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.
The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn’t visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?
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Solution
Acknowledge that the client is hearing voices but make it clear that the nurse doesn’t hear these voices.
Option C: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn’t hear the voices, the nurse avoids reinforcing the hallucination.
Option A: The nurse shouldn’t touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently.
Option B: Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client.
Option D: By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client’s feelings, rather than the content of the hallucination.
A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse’s first action is to:
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Solution
administer as needed dose of benztropine (Cogentin) I.M. as ordered.
Option B: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration.
Option A: Lorazepam treats anxiety, not extrapyramidal effects.
Option D: Another dose of haloperidol would increase the severity of the reaction.
A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He’s shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?
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Solution
“I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.”
Option B: Responses should focus on reality while acknowledging the client’s feelings.
Option A: Arguing with the client or denying his belief isn’t therapeutic.
Option C: Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis.
Option D: Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.
A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, “You’re worried about your medication?” The nurse’s communication is:
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Solution
focusing on emotional content.
Option C: The nurse should help the client focus on the emotional content rather than delusional material.
Option A: Presenting reality isn’t helpful because it can lead to confrontation and disengagement.
Option B: Agreeing with the client and supporting his beliefs are reinforcing delusions.
Option D: Mind reading isn’t therapeutic.