Question Of The Day: Psychotic Disorders

Q. A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, "Protect me, select me, reject me." The nurse should next:

A. Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol).
B. Place the client in temporary seclusion before he has a chance to hurt others.
C. Call the primary health care provider for a prescription for restraints.
D. Ask the other clients to leave the immediate area.

Correct Answer: A

Explanation: The client's anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the Ativan and Haldol will help the anxiety and delusions. He is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area is not necessary.