A patient admitted to a psychiatric facility is hallucinating, pacing, and acting highly suspicious. Based on this information, the nurse will take which action(s)? (Select all that apply.)
a. Use the most restrictive restraints available to subdue the patient.
b. Be open and direct when handling the patient.
c. Encourage a variety of interactions with others.
d. Provide high-protein, high-calorie foods.
e. Reinforce hallucinations.
ANS: B, D
Nursing interventions for patients with psychosis must be individualized and based on patient assessment data. The nurse should be open and direct when handling patients who are highly suspicious. High-protein, high-calorie foods are appropriate for the individual to eat while pacing or highly active. If physical restraints are necessary, they should be the least restrictive possible for the circumstances. Interactions should be minimized when perceptions are altered. Hallucinations should not be reinforced.
You might also like to view...
When assessing heart sounds, the nurse is aware that the time between S2 and S1:
A) Indicates inadequate blood pressure B) Indicates inadequate pulse pressure C) Corresponds to diastole D) Corresponds to systole
A registered nurse who worked in an extended care facility could see that a patient was in the process of dying. The lab technician came to draw his blood
The nurse requested that the blood draw be postponed for a while so that the patient's wife, who was at his bedside, could spend some quiet time with her husband. This is an example of which caring behavior? a. Providing presence b. Encouraging manner c. Healing environment d. Affiliation needs
Biophysiologic measures may be used as either independent variables or dependent variables in a study
A) True B) False
Which of the following is one of the four categories of client needs identified by the National Council of State Boards of Nursing?
A) Maintenance of function B) Restoration of wellness C) Psychosocial integrity D) Reduction of fear and worry