uba58ud0c8.docx - The nurse is caring for a client with...

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The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the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-care needs, fostering the ability to perform self-care
independently is a desirable client outcome.
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.
Since admission 4 days ago, a client has refused to take a shower, stating, "There are
poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which
nursing action is most appropriate?
A) Dismantling the showerhead and showing the client that there is nothing in it
B) Explaining that other clients are complaining about the client's body odor
C) Asking a security officer to assist in giving the client a shower
D) Accepting these fears and allowing the client to take a sponge bath

By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in
another way. Because these fears are real to the client, providing a demonstration of reality (as
in option A) wouldn't be effective at this time. Options B and C would violate the client's rights by
shaming or embarrassing the client.
Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which
adverse reaction?