Author Question: A client who has been seen responding to auditory hallucinations earlier in the morning approaches ... (Read 91 times)

Caiter2013 · **on:** Jul 19, 2018

A client who has been seen responding to auditory hallucinations earlier in the morning approaches
the nurse and shakes his fist, saying Back off, bitch and then goes into the day room.

The nurse
goes into the day room. The client continues to mumble and shake his fist. The nursing actions most
likely to be effective in achieving the outcome of de-escalation would be (more than one answer
may be correct)
A. telling the client that he is behaving inappropriately.
B. stating the client cannot be understood when he mumbles.
C. stating the expectation that the client will stay in control.
D. offering to provide the client with as-needed medication.

Question 2

The nurse psychotherapist looks at the records of the clients admitted over the weekend to determine
whom to include in the inpatient symptom management group focusing on self-esteem issues.

Which
client will the nurse consider inappropriate to bring into the group?
a. A, aged 32 years, a client with chronic paranoid schizophrenia
b. B, aged 59 years, a client with depression
c. C, aged 22 years, a client with panic disorder
d. D, aged 30 years, a client with antisocial personality disorder

lauravaras · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

C, D
Rationale: Stating the expectation that the client will maintain control of his behavior reinforces
positive, healthy behavior and avoids challenging the client. Offering as-needed medication provides
support for the client trying to maintain control. Option A: Belittling remarks such as this may lead
to aggression. Option B will be considered a criticism and probably prompt the client to begin
shouting.

Answer to Question 2

D
Clients with antisocial personality disorders frequently do not conform to social norms regarding
lawful behavior. They tend to be impulsive, have little regard for the truth, and use others for their
own ends. They do not benefit from group therapy, and they do not contribute to group cohesion or
goal attainment. The other clients could profit from the group experience.