A 25-year-old male with schizophrenia is brought to the emergency department by his family. He is exhibiting severe agitation, auditory hallucinations, and paranoid delusions. What are the nursing priorities for managing this patient in an acute situation?
(Select All that Apply.)
Administer prescribed antipsychotic medication as ordered.
Ensure the patient is in a safe environment to prevent harm to himself or others.
Monitor the patient for any side effects of medications.
Leave the patient alone to calm down in a quiet room.
Establish a relationship by using calm and clear communication.
Encourage the patient to participate in group therapy immediately.
Ignore the patient’s hallucinations and delusions to avoid reinforcing them.
Provide the patient with detailed explanations of their condition and treatment plan.
Correct Answer : A,B,C,E
Choice A reason: Administering prescribed antipsychotic medication is a priority in acute psychotic episodes to reduce agitation, control hallucinations, and stabilize thought processes. Prompt pharmacologic intervention can prevent escalation of symptoms and potential harm.
Choice B reason: Ensuring a safe environment is essential because patients experiencing psychosis are at increased risk of self-harm or harming others due to delusions and impaired judgment. Safety is always the first priority in emergency psychiatric care.
Choice C reason: Monitoring for side effects of medications is necessary because antipsychotics can cause acute adverse reactions such as dystonia, akathisia, or even neuroleptic malignant syndrome. Early recognition and intervention can prevent complications.
Choice D reason: Leaving the patient alone while highly agitated is unsafe, as the patient may harm themselves or others. Continuous supervision and therapeutic presence are needed.
Choice E reason: Using calm and clear communication builds trust, reduces paranoia, and helps orient the patient. Clear, simple language is effective when the patient’s cognitive processing is impaired.
Choice F reason: Group therapy is inappropriate during acute agitation. The patient must first stabilize before being introduced to therapeutic group settings.
Choice G reason: Ignoring hallucinations and delusions is not therapeutic. While the nurse should not reinforce false beliefs, acknowledging the patient’s feelings and providing reality orientation is best practice.
Choice H reason: Providing detailed explanations about the condition and treatment during acute psychosis is ineffective. The patient is unlikely to process complex information until stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response uses therapeutic communication by reflecting the client’s feelings, which encourages further expression and demonstrates empathy without judgment. It acknowledges the client’s concern while maintaining professional boundaries.
Choice B reason: This response, although supportive, does not focus on the client’s expressed feelings. It dismisses the concern by shifting to the nurse’s perspective rather than validating the client’s emotions.
Choice C reason: This is a dismissive and minimizing response. Suggesting deep breathing without addressing the underlying delusion fails to use therapeutic communication techniques in mental health care.
Choice D reason: This response is confrontational and places the client in a defensive position. It may escalate agitation and is not consistent with therapeutic communication principles.
Correct Answer is D
Explanation
Choice A reason:Asking the client why he thinks the pain isn’t from hiking may come across as dismissive and could heighten his anxiety. It does not address his concerns constructively or facilitate a medical evaluation to determine the cause of the pain.
Choice B reason:Reassuring the client that bone cancer is unlikely without a medical evaluation is inappropriate, as it may minimize his concerns and delay necessary assessment. The nurse should avoid making diagnostic assumptions without provider input.
Choice C reason:Suggesting genetic testing is premature without a medical evaluation to determine if the pain warrants such testing. The client’s pain is likely related to hiking, and a provider’s assessment should guide any further diagnostic steps.
Choice D reason:Explaining that a provider will evaluate the client and determine the next steps is the most appropriate action. This response validates the client’s concerns, ensures a professional assessment of the knee pain, and provides a clear path forward without making assumptions about the cause.
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