A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:

Correct Answer: B

Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his specific delusion of food being poisoned. By allowing the client to select food from vending machines, he can choose items he believes are safe, which can help alleviate his paranoia and increase his trust in the care being provided. This approach promotes a therapeutic relationship and empowers the client in making choices about his care. Explanation of why other choices are incorrect: A: Explaining that others eat the food and are not harmed may not be effective as the client's delusion is strong, and rational arguments may not be helpful in this case. C: Assisting with personal hygiene and grooming is important but does not directly address the client's delusion about food being poisoned. D: Not allowing the client to verbalize delusional thoughts can escalate the client's distress and hinder the therapeutic relationship. It is essential to acknowledge the client's experiences and work towards building trust and rapport

Correct Answer: C

Rationale: The correct answer is C because disorganized schizophrenia is characterized by social withdrawal and ineffective communication. This subtype of schizophrenia involves disorganized speech and behavior, flat or inappropriate affect, and disorganized thinking. Patients with this type may display bizarre or nonsensical behavior and have difficulty with daily activities. Choice A is incorrect as suspiciousness and delusions are more commonly associated with paranoid schizophrenia. Choice B is incorrect as extremes of motor activity and excitement to stupor are characteristic of catatonic schizophrenia. Choice D is incorrect as severe anxiety and ritualistic behavior are not typical features of disorganized schizophrenia.

Correct Answer: A

Rationale: The correct answer is A: neuroleptic malignant syndrome (NMS). NMS is a rare but serious adverse reaction to antipsychotic medications like risperidone. The patient's symptoms of severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, and elevated temperature, pulse, and blood pressure are all consistent with NMS. The nurse should suspect NMS due to the constellation of symptoms and vital sign changes. Placing the patient in a cooling blanket and transferring to the ICU is appropriate as NMS is a medical emergency requiring prompt intervention to lower the body temperature and provide supportive care. Choices B, C, and D are incorrect: B: Anticholinergic toxicity does not typically present with the specific symptoms described, such as muscle stiffness and stupor. C: Relapse of psychosis would not explain the acute onset of symptoms and vital sign changes seen in the scenario. D: Agranulocytosis is a rare side effect of some ant

Correct Answer: B

Rationale: The correct answer is B because engaging in activities that require physical skills and constructive use of time can help the patient shift their focus away from the delusions. Physical activities can help reduce anxiety and provide a sense of accomplishment, which can help distract the patient from the delusions. It also promotes a sense of normalcy and routine, which can aid in grounding the patient in reality. Choice A is incorrect because reading and listening to music may not actively engage the patient in a way that helps them shift their focus from the delusions. Choice C is incorrect because planning for discharge may be premature and may not address the immediate need to distract the patient from the delusions. Choice D is incorrect because discussing personal goals related to improved socialization may not be effective in helping the patient focus less on the delusions at this stage.

Correct Answer: D

Rationale: The correct answer is D because understanding how the patient reacts to family dynamics is crucial for discharge planning. Anxiety triggered by family conflict can impact the patient's well-being post-discharge. Choices A, B, and C are less relevant as they do not directly address the patient's immediate needs or potential stressors. Middle sibling status, maternal artistic talent, and paternal grandfather's eccentricity are interesting but not as directly impactful on the patient's discharge planning compared to the patient's response to family conflicts.