A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?

Correct Answer: D

Rationale: The correct answer is D: Escort the client to his room. This intervention is best because it addresses the behavior causing disturbance without isolating the client or administering unnecessary sedatives. By escorting the client to his room, the nurse provides a supportive and non-punitive approach to managing the behavior. It allows the client to have a quiet space to calm down, reducing the annoyance to other clients. Isolating the client may worsen the behavior or create feelings of abandonment. Administering a sedative should be avoided unless absolutely necessary to ensure client safety. Avoiding recognizing the behavior does not address the issue or provide any support to the client.

Correct Answer: A

Rationale: The correct answer is A: Make observations. This technique is effective because it allows the nurse to show nonjudgmental acceptance and support without pressuring the patient to engage in lengthy conversations. By making observations, the nurse can acknowledge the patient's behavior without requiring a response, thus respecting the patient's need for space and limited interaction. Option B: Asking the patient direct questions may feel intrusive and overwhelming for someone with major depressive disorder who is withdrawn. Option C: Phrasing questions to require yes or no answers limits the patient's ability to express themselves fully and may not promote a sense of support and acceptance. Option D: Frequently reassuring the patient to reduce guilt feelings may come across as insincere or patronizing, and may not address the patient's need for nonjudgmental acceptance in communication.

Correct Answer: B

Rationale: The correct answer is B: Risk for suicide. The patient's belief of having cancer as punishment indicates distorted thinking and a high level of hopelessness, which increases the risk for suicide. This is a priority because it addresses the immediate safety of the patient. Powerlessness (A) may be relevant but doesn't address the imminent risk of harm. Stress overload (C) is not as critical as suicide risk in this scenario. Spiritual distress (D) may be present but doesn't address the immediate safety concern of potential suicide.

Correct Answer: C

Rationale: Rationale: C is correct because it addresses the patient's concern by explaining the time lag before antidepressants relieve symptoms. It educates the patient on the delayed onset of action for antidepressants, setting realistic expectations. A: Increasing the dose without waiting for the full effect can lead to adverse effects. B: Reassurance without providing education may not address the patient's misunderstanding. D: Critical assessment for improvement is important, but educating the patient about the medication is the immediate priority.

Correct Answer: B

Rationale: The correct answer is B. This statement indicates understanding of potential side effects of TMS, which may include dizziness or mild headaches post-procedure. This shows the patient has grasped the information provided during teaching. Choice A is incorrect as TMS does not require anesthesia. Choice C is incorrect as TMS does not typically require extended recovery time. Choice D is unrelated to the procedure and pertains to dietary restrictions for MAOIs.