Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis
of paranoid schizophrenia?
Continual pacing
Suspicious feelings
Inability to socialize with others
Disturbed relationship with the family - Answers Suspicious feelings
The nurse must consider the client's suspicious feelings and establish basic trust to promote a
therapeutic milieu. Continual pacing is not a problem because the nurse can walk back and forth with
the client. Inability to socialize with others and disturbed relationship with the family may be of long-
range importance but have little influence on the nurse-client relationship at this time.
A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial
for this client?
Directing the client repeatedly to eat the food
Explaining to the client the importance of eating
Waiting and allowing the client to eat whenever the client is ready
Having a staff member sit with the client in a quiet area during mealtimes - Answers Having a staff
member sit with the client in a quiet area during mealtimes
By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this
encourages the client to eat and begins the construction of a trusting relationship. Fewer distractions
may help the client focus on eating. The client will not follow directions to eat because of the nature of
the illness. Explaining the importance of eating and allowing the client to eat when ready are both
unrealistic and will not ensure adequate intake.
A client with paranoid schizophrenia tells the nurse, "My neighbors are spying on me because they want
to rob me and take money." While hospitalized, the client complains of being poisoned by the food and
of being given the wrong medication. The nurse evaluates the client's response to medications and
,therapy. Which assessment finding leads the nurse to conclude that the client's reality testing has
improved?
The client eats the food provided on the hospital tray.
The client discusses his discharge plans with the staff.
The client questions each medication when it is administered.
The client asks permission to make phone calls to the hospital administration - Answers The client eats
the food provided on the hospital tray.
Because the client was admitted while complaining that the food was poisoned, eating the food on the
tray indicates that the client feels safe. Discussing discharge plans with the staff does not provide
adequate behavioral assessment with which the nurse can evaluate reality testing. Questioning each
medication when it is administered indicates that the client still does not completely trust the staff.
Asking permission to make phone calls to the hospital administration seems to indicate that the client
still does not trust the staff and is attempting to intimidate the staff by calling the administration.
A client with catatonic schizophrenia who is in a vegetative state is admitted to the psychiatric hospital.
The nurse identifies short- and long-term outcomes in the client's clinical pathway. What is the priority
short-term outcome of care that the client should be able to attain?
Talking with peers
Performing her own activities of daily living
Completing unit activities and assignments
Ingesting adequate fluid and food with assistance - Answers Ingesting adequate fluid and food with
assistance
A client in a vegetative state may not eat or drink without assistance; fluids and foods are basic
physiologic needs that are necessary to prevent malnutrition and starvation; therefore the intake of
adequate fluid and food is a priority short-term goal. The client is in total withdrawal; talking with peers,
performing activities of daily living, and completing activities and assignments are not priority outcomes
at this time.
, A 56-year-old man is admitted to the inpatient unit after family members report that he seems to be
experiencing auditory hallucinations. The man has a history of schizophrenia and has had several
previous admissions. Which statement indicates to the nurse that the client is experiencing auditory
hallucinations?
"Get these horrible snakes out of my room!"
"I am not the devil! Stop calling me those names!"
"The food on this plate has poison in it, so take it away—I won't eat it."
"I did see an alien spaceship last night outside in my yard, and I've felt worse ever since." - Answers "I
am not the devil! Stop calling me those names!"
The client is responding to messages that he is hearing, which are auditory hallucinations. The responses
regarding the snakes and the spaceship are examples of visual hallucinations because they describe
what the client sees. The accusation of poisoning is the statement of a client who is suspicious and
paranoid but not hallucinating.
What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled
by others?
Express disbelief about the client's delusion.
Divert the client's attention to unit activities.
React to the feeling tone of the client's delusion.
Respond to the verbal content of the client's delusion - Answers React to the feeling tone of the client's
delusion.
Reacting to the feeling tone of the client's delusion helps the client explore underlying feelings and
allows the client to see the message that his verbalizations are communicating. Expressing disbelief
about the client's delusion denies the client's feelings rather than accepting and working with them.
Attempting to divert the client rather than accepting and working with him denies the client's feelings.
Responding to the verbal content of the client's delusion focuses on the delusion itself rather than on
the feeling that is causing the delusion.