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					            Thought Disorders



            Adrianne Maltese




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Etiology of schizophrenia
   Most likely caused by a convergence/interaction
    of genetic and environmental factors:
   GENETIC factors:
   Neurodevelopmental – brain abnormalities
       Enlarged ventricles
       Cortex-left localized
       Temporal lobe dysfunction
       Phospholipid metabolism
       Frontal lobe dysfunction
       Brain circuitry dysfunction
       Neuronal density
       NEUROTRANSMITTER SYSTEM

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            Schizophenria

               BLEULER’S four A’s
               Ambivalence—holding two
                different attitudes/emotions/feelings
                at the same time
               Autistic thinking—disturbances in
                thoughts –private fantasy
                world/abnormal responses to
                people/events of the real world


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            Bleuler’s 4 A’s(cont)

               Loosening of Associations-rapid
                shift of ideas- unrelated manner
               Affective disturbance - may be
                blunt, flat,inappropriate/labile




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            Positive Symptoms

   DELUSIONS(paranoid/reference)
   HALLUCINATIONS(auditory/visual)
   DISORANIZED
    SPEECH/THINKING(tangential/loa/incoherent/n
    eologisms
   GROSSLY DISORGANIZED BEHAVIOR(difficulty
    with goal setting/ADL’s;unpredictable
    agitation/silliness/social disinhibition/bizarre
    behaviors
   CATATONIC BEHAVIORS(decrease reaction to
    environment/bizarre postures/aimless motor
    activity)
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            Negative symptoms

               AFFECTIVE FLATTENING
               ALOGIA (poverty of speech/slowed
                speech/decrease fluency/content)
               AVOLITION(inability to initiate goal
                directed behavior)




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            Types of Schizophrenia
             Disorganized
             Paranoid
             Catatonic
             Undifferentiated
             Residual
            Related Psychotic Disorders:
              Schizoaffective Disorder
              Schizophreniform disorder
              Delusional disorder
              Brief Psychotic disorder


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            Paranoid Type
   Persistent delusions/persecuatory nature
   Auditory hallucinations-single or associated
    theme
   Guarded,suspicious,hostile,angry,
    possibly violent
   Pervasive anxiety
   Intensive,reserved,controlled social interactions
   Onset- later in life
   Generally more favorable dx. re: independent
    living/occupational functioning.


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            Disorganized type


             Grossly inappropriate/flat affect
             Primitive / uninhibited behaivor
             Unusual mannerisms-giggle/cry out
              loud/distort facial expressions
             Hypochondriasis (multiple physical
              complaints)
             Socially inept/withdrawn
            Onset early- prepsychotic period- marked
              adjustment problems
            Hallucinations/delusions more fragmented

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      Catatonic Type

            Marked     disturbance of
            psychomotor activity
            May be immobile/or with
            psychomotor excitation
            Displays negativism/mutism

            Posturing

            Bizarre positions-waxy
            flexibility
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            Undifferentiated type

               Florid psychotic symptoms :
                   delusions/hallucinations
                   incoherence
                   disorganized speech/behavior
                  *do not clearly fit into other
                categories



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            Schizophreniform Disorder
               Meets criteria for schizophrenia except:
                1) duration-at least 1 month but < 6
                mos.

                2)Social/ Occupational functioning may or
                may not be impaired vs. schizophrenia
                where functional disturbances
                ie:relationships,school,self care are
                present.


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            Schizoaffective Disorder
             Symptoms of both Schizophrenia and
              affective (mood)disorders
            *delusions/hallucinations/disorganized
              speech
             Major depression, mania, mixed
             At least a two week period of psychotic
              symptoms only
             Onset is later than schizophrenia
             Prognosis is better than schizophrenia,but
              worse than Affective Disorder.

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            Residual Type

               Client has had at least one acute
                episode
               Free of psychotic symptoms
               Continues to exhibit persistent
                social withdrawal/emotional
                blunting/illogical
                thinking/eccentric behavior


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            Delusional Disorder

               Presence of one or more nonbizarre
                delusions persist for ONE month or
                more
               Bizarre delusion ie:brain removed
                by aliens-replaced with computer
               vs. nonbizarre delusion- more
                believable ie:believes the IRS is
                going to prosecute his family for his
                wrongdoings.
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            Subtypes of Delusional Disorder
               Erotomanic—may involve stalking/spying
               Jealous—efforts made to follow & “Catch”
               Grandiose—has extraodinary
                talent/knowledge
               Persecutoy-victim of a
                conspiracy/poisining/spying
               Somatic-bodily sensations/believes body
                has a foul odor/insects or parasites on/in
                body/body part is nonfunctional


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            Other Psychotic disorders

             BRIEF PSYCHOTIC DISORDER
                 At least one of the following sx’s:
                 Hallucinations,delusions,
                 disorganized speech,
                 behavior disturbance,(disorganized or
                  catatonic)
                 Sx’z last at least one day—but less
                  than one month.—returns to premorbid
                  level.

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            SHARED PSYCHOTIC
            DISORDER

               Delusional disorder– also known as
                   “folie `a deux”
                develops in a person who is
                involved in a relationship with
                another person who already has a
                psychotic d/o with prominent
                delusions.



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            Psychotic Disorder due to medical
            conditions

               Characterized by: prominent
                hallucinations and /or delusions due
                to physiologic effect of medical
                condition




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            Substance Induced Psychotic
            Disorder

               Characterized by: prominent
                hallucinations and /or delusions
                produced by the physiological
                effects of a substance ie:
                   Drugs of abuse,medications or toxins
                   The disorder first occurs during
                    intoxication or withdrawal stages, but
                    can last for weeks thereafter.



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            Human Needs Assessment:
            Maslow

               Biologic & Physiologic Integrity:
                (Air, Fluids , Comfort, Activity,
                Nutrition, Elimination, Skin
                Integrity)
                   Overall Decline in health maintenance
                   Poor grooming/hygiene/ADL functions
                   Increased risk for communicable
                    diseases r/t i.e. TB, PNA, Infection
                    homelessness & poor hygiene, poor
                    judgment
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            Oxygen & Fluids Assessment
            -   Note hx. of cigarette smoking –second
                hand in smoke filled facilities, Respiratory
                diseases
            -   Poor posture – shallow breathing patterns
            -   May drink too little or too much water due
                to delusional beliefs
            -   May be dehydrated upon admission
            -   Check Chem panel and
                electrolytes(hypo-hyper nutremia ;hypo-
                hyper kalemia)


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            Mental Status Assessment

               Altered mood/depressive symptoms
               Anxiety/agitation
               Social withdrawal/isolation
               Perceptual distortions:
                   Hallucinations, illusions,altered internal
                    sensations,Agnosia,distorted body
                    image,negative self-perception



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            Comfort, Activity

               Assess Pain, discomfort ,injuries

               Activity level – normal vs.
                Psychomotor retardation,
                psychomotor agitation




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            Mental Status Assessment

               Cognitive Distortions:
                   Delusions,derealizations,ideas of
                    reference,errors in memory
                    recall,problems with
                    attention/concentration
                   Incorrect use of language which
                    interferes with socialization
                    (neologosisms/clanging)
                   Flight of ideas


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            Nutrition, Elimination, Skin Integrity
   Assess food intake ?mal-nourishment – where
    does client get food supply? # meals daily,
    usual diet, % eaten while on unit?
   B12 & Folate levels, Liver Panel, CBC w/diff ,
    Protein levels
   Assess constipation/loose stools r/t S/E’s of
    psychotropic meds.
   Assess Skin Integrity- condition of skin- dry,
    cracked, sun-burned
   Foot care – may walk barefoot on surface
    streets

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            Safety & Security Assessment

               Assess suicidal ideation(50% suicide
                rate)
               Assess potential for
                violence/aggression
               Maintain safe/secure environment
               Assess orthostatic B/P changes
               Assess Mental Status changes


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            Belonging & Attachment
            Assessment (Psychosocial)

               Assess support system (effective or
                not?)
               Family attachments, friends, clergy,
                12 step groups)
               Affect- may be labile, emotionless
               Coping ability
               Ability to form trusting & reciprocal
                relationships

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            Self-Esteem & Self Efficacy
            Assessment

               What is client’s view of self ?(was
                education interrupted by illness?)
               Body image (distorted or realistic)
               What stage of development was
                effected by onset of illness?
               Decision making capacity
               Sense of control over life


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            The Nursing Process:

               Assessment: Subjective/Objective
                   Use of the Mental status exam
                   Focus on four areas:disturbances in
                    perceptions, Language & thought
                    Process, affect &feelings, and
                    Psychomotor behavior.
                   Direct questions towards assessment of
                    these areas



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            Self Actualization & Self-
            Transcendence Assessment

               Ability to maintain health-
                compliance with med regime
               Ability to seek help when needed –
                keeps Dr.’s appt’s for f/u of illness
               Seeks ways to control stress




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            Psychosocial Assessment

               Behavioral disturbances:
                   Poor impulse control/anger
                    management problems
                   High risk for self harm (50% risk for
                    Suicide)
                   Lack of social support systems
                   Substance abuse/med noncompliance




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            Psychosocial Assessment

               Poor peer relationships-has few
                friends
               Social/occupational areas –poor
                functions
                   Preoccupied/detached
                   Poor achievements-lacks
                    competativeness
                   Avolition- lacks initiative to engage in
                    self-initiated, goal –directed activity.
                   Social withdrawal/self isolation
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            Developmental Assessment

               Autistic like behaviors-lacks social
                skills
               Delayed development- immature
               Strikes in late adolescence—early
                adulthood effecting emotional
                development.
               Erikson’s stage(identity vs. role
                confusion)
                (intimacy vs. isolation)
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            Spiritual Assessment

               Religiosity- delusional beliefs
                centered around religious beliefs
               Values and beliefs with which one is
                raised
               Impact of these beliefs on
                delusional system




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            Nursing Diagnosis
            (Actual or Potential)

               Communication, Impaired verbal
               Disturbed personal Identity
               Coping, Ineffective Individual
               Family Process, altered
               Sensory/ perceptual alterations
               Thought processes, altered
               Violence, risk for: self/other directed
               Altered nutrition < body requirements
               Self care deficit
                (bathing/hygiene/grooming/
                    bathing/feeding/toileting)
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            Outcome Identification/goals
            The client will:
             Demonstrate reduction in psychotic symptoms
             Demonstrate absence of self-mutilating,violent or
              aggressive behaviors
             Demonstrate reality based thinking & behaviors
             Socialize with peers/staff&participate in groups
             Comply with medication regimen
             Verbalize the role of medications in reduction of
              psychotic symptoms.




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            Nursing Interventions/Rationales:
             Involve client/family in treatment process
              (avoids misunderstandings;resistance
              from client/family/or
              financial/environmental constraints)
                 Establish a therapeutic relationship with client
                  first (the client must first feel he can trust the
                  nurse-assists with safety and security)
                 Institute measures to maintain/regain physical
                  health (the client’s safety and physical health
                  are priority!)



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            Interventions/rationales
               Use clear/concrete statements vs.
                generalizations (they may exacerbate
                misperceptions or hallucinations)
               Determine stressors that may trigger
                sensory-perceptual disturbances
                (hallucinations may be exacerbated by
                external/environmental stressors)




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            Interventions/rationales

               Distract client from delusions that
                exacerbate aggressive/potentially
                violent episodes (engaging the
                client in more functional,less
                anxiety provoking activities
                increases the reality base and
                decreases risk of violent episodes
                that may be provoked by delusions)


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            Interventions/rationales
               Begin with one to one interactions, accompany
                client to group activities starting with more
                structured, less threatening groups and
                progressing to more informal spontaneous
                activities(limited contact at first-often better
                tolerated – later increase in socialization to assist
                with social skills & to expand reality base)
               Focus on meaning behind delusion rather than
                content-recognize as client’s perception of the
                environment(meets clients needs,reinforces
                reality,non challenging or threatening)




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            Questions-Thought disorders&
            Schizophrenia:
            1.   A client is a withdrawn catatonic state
                 exhibits waxy flexibility. During the
                 initial phase of hospitalization for this
                 client the nurse’s first priority is to:
            A.   Watch for edema and cyanosis of the
                 extremities.
            B.   Encourage the client to discuss concerns
                 that led to the catatonic state.
            C.   Provide warm, nurturing, relationship,
                 with therapeutic use of touch.
            D.   Identifying the predisposing factors to
                 the illness.

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2. A client with schizophrenia, disorganized type
    is admitted to the inpatient unit. He
    frequently giggles and mumbles to himself.
    He hasn’t taken a shower in 3 days. His
    appearance is disheveled and unkempt. The
    nurse would best persuade the client to
    shower by saying:
A.  “Clients on this unit take showers daily.”
B.  “It’s time to shower, I will help you.”
C.  “You’ll feel better if you shower.”
D.  “Would you like to take a shower?”



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3. The nurse identifies the nursing diagnosis of
   Disturbed thought process related to
   exhibiting delusions of reference for a client
   with schizophrenia. Which outcome would be
   most appropriate?
A. Client will talk about concrete events in the
   environment without talking about delusions.
B. Client will state 3 symptoms that occur when
   feeling stressed.
C. Client will identify 2 personal interventions
   that decrease intensity of delusional thinking.
D. Client will use distracting techniques when
   having delusions.



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            4. During a community meeting, a client
                with schizophrenia begins to shout and
                gesture in an angry manner. Which
                nursing intervention would be the
                priority?
            A.  Determine the reason for the client’s
                agitation.
            B.  Encourage appropriate group behavior?
            C.  Facilitate group process in responding to
                the client.
            D. Maintaining safety of client and others.

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     A male client who has schizophrenia is
      admitted to the inpatient psychiatric unit.
      The client is actively hallucinating and is
      unable to provide information for the
      admission process. What is the nurse’s best
      option for getting information?
A.    Wait until the medication works
B.    Ask the next shift to do the admission
C.    Get the information from the physician
D.    Ask the client’s family for information.




10/2/2012                                           46
      A 32 year-old client admitted with
       catatonic schizophrenia has been mute
       and motionless for 2 days. The priority
       nursing diagnosis is:
A.     High risk for fluid and electrolyte
       imbalance
B.     Impaired mobility
C.     Impaired verbal communication
D.     Ineffective individual coping.




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     In planning care for a client
      experiencing paranoid delusions, which
      of the following is the priority goal?
A.    Absence of delusions
B.    Establishing trust
C.    Participation in all unit activities
D.    Performing independent activities




 10/2/2012                                     48
     Which nursing response would be most
      appropriate when a client is hearing voices?
A.    “I do not hear the voices that you say you
      hear.”
B.    “Those voices will disappear as soon as the
      medicine works.”
C.    “Try to think about positive things instead of
      the voices.”
D.    “Voices are only in your imagination.”




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    The nurse expects to assess which of the
     following in a client diagnosed with
     schizophrenia, paranoid type?
A.   Anger, auditory hallucinations, persecutory
     delusions.
B.   Abnormal motor activity, frequent posturing,
     autism.
C.   Flat affect, anhedonia, alogia.
D.   Silly behavior, poor personal hygiene,
     incoherent speech.




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            AGGRESSIVE BEHAVIORS

            “Aggressive behavior” - is an acting
              out of aggressive or hostile
              impulses in a violent or destructive
              manner; may be directed towards
              objects, others, self.
            ETIOLOGY- r/t feelings of
              anger/hostility/homicidal
              ideation,psychotic
              process,substance use, personality
              disorders
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    Which of the following comments by a
     client indicate the need for an urgent
     dose of an antipsychotic drug?
A.   “The voices are mumbling and I can’t
     hear them very well.”
B.   “The voices are telling me to rip my bed
     sheets and hang myself.”
C.   “The voice I heard this morning
     sounded like my dead grandmother.”
D.   “The voices told me to kill my neighbor
     when I get home.”

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            De-escalating Aggressive
            Behaviors
                GENERAL INTERVENTIONS –
                 SAFETY –most important- protect client &
                 others
                 Provide safe, non-threatening
                 Therapeutic environment




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            LEGAL /ETHICAL ISSUES – Staff is
             responsible to provide control to protect
             client & others

            MANAGING THE ENVIRONMENT-
                  Persuade client to move to another area;
                   have colleagues remove others from area
                   (prevents anxiety/contagious responses from
                   other clients/provides sense of
                   safety/protects others)




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            De-escalation techniques:

               Encourage Verbalization
                   Ask the client open-ended ,non-
                    threatening questions
                   “How?” “What?” “Where?” “When?” –
                    obtain details from client .
                   Do NOT ask “WHY?”
                   Keep voice calm,modulated(focuses on
                    client problem-stops anger from
                    escalating


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            De-escalating techniques cont’d

               Use of Non-Verbal expression:
                   Allow client body space > 8 feet
                   Keep your body at a 45 degree angle
                   Assume “OPEN POSTURE” –hands at
                    side,palms outward. [this conveys a
                    non-threatening message, gives client
                    message that you are willing to listen
                    and help]



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            De-escalating techniques

               Personalize self and show concern
                   Remind client who you are (that you
                    are his nurse-he is in the hospital and
                    is safe here)
                   Use words ie: “we” or “us”
                   Use encouraging responses ie: “go
                    on…”[demonstrates
                    empathy/encourages and reflects
                    cooperation on your part]


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            Managing aggressive Behaviors

               Hold regular drills with staff to
                practice strategies
               Practice use of disengagement
                breakaways
               Rehearse procedures regarding the
                removal of client to seclusion or
                restraints
               Document all events and hold
                debriefing sessions with staff
10/2/2012
                [allows staff to de-escalate and  58
    A client who is agitated begins to shout
     insults and threats at others, and starts
     demolishing the recreation room. What is the
     best response or action by the nurse?
A.   Firmly set limits on the behavior.
B.   Allow the client to continue, because this is an
     expression of his/her feelings.
C.   Let the client know that he/she does not need
     to express anger at the nurse by demolishing
     the recreation room.
D.   Tell the client that he/she is trying to
     intimidate other clients.




10/2/2012                                           59
    A client who is agitated begins to shout
     insults and threats at others, and starts
     demolishing the recreation room. What is the
     best response or action by the nurse?
A.   Firmly set limits on the behavior.
B.   Allow the client to continue, because this is an
     expression of his/her feelings.
C.   Let the client know that he/she does not need
     to express anger at the nurse by demolishing
     the recreation room.
D.   Tell the client that he/she is trying to
     intimidate other clients.




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    Which nursing intervention is inappropriate to
     use with a person who is expressing anger?
A.   Stating observations of the expressed anger.
B.   Assisting the person to describe his/her
     feelings.
C.   Helping the person find out what preceded
     the anger.
D.   Helping the person refrain from expressing
     the anger verbally.




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     A teenager with acting-out behaviors tells the
      nurse, “I want you to go tell my teacher that I
      am sick and I should be allowed to do
      whatever I want.” The nurse determines that
      this statement best represents:
A.    Insight
B.    Manipulation
C.    Dependency
D.    Trust




 10/2/2012                                          62
    A client who is acutely agitated becomes increasingly
     aggressive despite staff’s verbal attempts to stop the
     aggression. The client shout threats at other clients,
     throws furniture, and begins to kick and bite clients
     and staff. A prn order for medication when agitated
     is available. Which action should the nurse take
     initially?
A.   Orient the client to reality, and place the client in a
     well lit, quiet room.
B.   Give the ordered tranquilizer and pout the client in
     bed with the side rails up.
C.   Lock the client in his/her room and call the doctor.
D.   Have at least two staff members physically restrain
     the client and take the client to a quiet room.




 10/2/2012                                                 63
 Which nursing action would be best for a client
  who is hospitalized , and is constantly upset
  with the staff, easily angers, and frequently
  shouts at the nurses?
A Request that the client be moved to another
  unit.
B. Schedule a conference with the MD, nurse
  manager, and client about his behavior.
C. Contact social services to meet with the client
  and family about the problem.
D. Involve the client and the family in the
  development of the care plan.




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