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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 himselfB) The client doesn't engage in delusional thinkingC) The client doesn't harm himself or othersD) The client demonstrates ability to meet his own self-care needsThe client with schizophrenia is commonly socially isolated and withdrawn; therefore, having theclient spend more time by himself wouldn't be a desirable outcome. Rather, a desirable outcomewould 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 interactionsB) Establishing a one-on-one relationship with the clientC) Establishing alternative forms of communicationD) Allowing the client to decide when he wants to participate in verbal communication with the nurseBy 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 itB) Explaining that other clients are complaining about the client's body odorC) Asking a security officer to assist in giving the client a showerD) 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 inanother 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 byshaming or embarrassing the client.Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction?