a young adult male client diagnosed with paranoid schizophrenia believes that world is trying poison him what intervention should the nurse include i
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?

Correct answer: B

Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. Choice (A) is argumentative and may increase the client's resistance. Choice (C) might be too overwhelming and anxiety-provoking for the client. Choice (D) could increase the client's stress and anxiety, which are counterproductive in managing paranoid ideations.

2. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?

Correct answer: A

Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.

3. The nurse plans to help an 18-year-old female intellectually disabled client ambulate on the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, 'Get out of here! I'll get up when I'm ready!' Which response is best for the nurse to make?

Correct answer: D

Rationale: (D) provides a 'cooling off' period, is firm, direct, non-threatening, and avoids arguing with the client. (A) is avoiding responsibility by referring to the healthcare provider. (B) is trying to reason with an intellectually disabled client and is threatening the client with 'complications.' (C) is telling the client how she feels (angry), and the nurse does not really 'know' how this client feels, unless the nurse is also intellectually disabled and has also just had an appendectomy.

4. A client with panic disorder is prescribed sertraline (Zoloft). What is the most important information for the nurse to provide?

Correct answer: B

Rationale: The correct answer is B. SSRIs like sertraline may take several weeks to reach their full therapeutic effect, so it's important to inform the client to be patient with the treatment. Choice A is not the most crucial information regarding sertraline. Choice C is not a common side effect of sertraline. Choice D is important but not as crucial as informing about the delayed onset of action.

5. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?

Correct answer: B

Rationale: The correct answer is B: 'Tells when voices decrease.' This outcome indicates improvement because it shows that the client is experiencing a reduction in auditory hallucinations. By communicating that the voices are decreasing, it suggests that the client's symptoms are improving and the treatment is effective. Choices A, C, and D are incorrect. Arguing with the voices (A) indicates ongoing engagement with the hallucinations, which is not a positive outcome. Following what the voices say (C) suggests compliance with the hallucinations, which is not indicative of improvement. Lastly, telling the nurse what the voices say (D) does not necessarily demonstrate a reduction in hallucinations or improvement in the client's condition.

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