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The nurse is caring for a client with schizophrenia. Which of the
following outcomes is the least desirable?
A)The client spends more time by himself
B)The client doesn't engage in delusional thinking
C)The client doesn't harm himself or others
D)The client demonstrates ability to meet his own self-care needs
The client with schizophrenia is commonly socially isolated and
withdrawn; therefore, having the client spend more time by
himself wouldn't be a desirable outcome. Rather, a desirable
outcome would specify that the client spend more time with other
clients and staff on the unit. Delusions are false personal beliefs.
Reducing or eliminating delusional thinking using talking therapy
and antipsychotic medications would be a desirable outcome.
Protecting the client and others from harm is a desirable client
outcome achieved by close observation, removing any dangerous
objects, and administering medications. Because the client with
schizophrenia may have difficulty meeting his or her own self-
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care needs, fostering the ability to perform self-care
independently is a desirable client outcome.
A client is about to be discharged with a prescription for the
antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per
day. During a discharge teaching session, the nurse should provide
which instruction to the client?
A) Take the medication 1 hour before a meal.
B) Decrease the dosage if signs of illness
decrease C)Apply a sunscreen before
being exposed to the sun.
D) Increase the dosage up to 50 mg twice per day if signs of illness
don't decrease.
Because haloperidol can cause photosensitivity and precipitate
severe sunburn, the nurse should instruct the client to apply a
sunscreen before exposure to the sun. The nurse also should
teach the client to take haloperidol with meals — not 1 hour
before — and should instruct the client not to decrease or
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increase the dosage unless the physician orders it.
A client with paranoid schizophrenia repeatedly uses profanity during
an activity therapy session. Which response by the nurse would be
most appropriate?
A)"Your behavior won't be tolerated. Go to your room immediately."
B)"You're just doing this to get back at me for making you come to
therapy."
C)"Your cursing is interrupting the activity. Take time out in your room
for 10 minutes."
D)"I'm disappointed in you. You can't control yourself even for a few
minutes."
The nurse should set limits on client behavior to ensure a
comfortable environment for all clients. The nurse should accept
hostile or quarrelsome client outbursts within limits without
becoming personally offended, as in option A. Option B is
incorrect because it implies that the client's actions reflect
feelings toward the staff instead of the client's own misery.
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Judgmental remarks, such as option D, may decrease the client's
self-esteem.
The nurse formulates a nursing diagnosis of Impaired verbal
communication for a client with schizotypal personality disorder.
Based on this nursing diagnosis, which nursing intervention is most
appropriate?
A) Helping the client to participate in social
interactions B) Establishing a one-on-one
relationship with the client
C) Establishing alternative forms of communication
D) Allowing the client to decide when he wants to participate in
verbal communication with the nurse
By establishing a one-on-one relationship, the nurse helps the client learn how to
interact with people in new situations. The other options are appropriate but
should take place only after the nurse-client relationship is established.
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