A mental health nurse is assigned to care for a client with a diagnosis of undifferentiated schizophrenia. The nurse uses which of the following approaches when planning care for this client?
1. Allow the client to set the goals for the plan of care.
2. Let the client act out initially, and use the quiet room and restraints as needed.
3. Provide assistance with grooming and nutrition until the client's thinking has cleared.
4. Repeatedly point out inconsistencies in the client's communication during initial treatment.
3
Rationale: In the acute phase, the nurse must assume responsibility for planning for the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living (ADLs). As the nurse plans care for the schizophrenic client, it is important to understand the client's devel-opmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. "Allow the client to set the goals for the plan of care" and "let the client act out initially, and use the quiet room and restraints as needed" are incorrect because these actions do not provide a structured routine. "Repeatedly point out inconsistencies in the client's communication during initial treatment" is a nonthera-peutic communication technique.
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