A 28-year old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
Orienting the client to the unit
Reinforcing reality with the client
Establishing a nonthreatening relationship
Assessing the client for physical problems
The Correct Answer is D
A. Orienting the client to the unit While orientation is important, the client's prolonged
immobility and stupor necessitate a physical assessment first to ensure there are no underlying medical issues contributing to this state.
B. Reinforcing reality with the client The client's catatonic state may make it difficult to effectively communicate or engage in reality orientation at this point. Addressing potential physical issues is the initial priority.
C. Establishing a nonthreatening relationship Building a therapeutic relationship is crucial, but given the client's current state, assessing for physical problems takes precedence.
D. Assessing the client for physical problems The client's prolonged catatonic state requires an
immediate physical assessment to rule out any underlying medical conditions contributing to his condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B. A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C. A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D. Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.
Correct Answer is C
Explanation
A) Incorrect. This statement does not provide relevant information about the medication or potential risks.
B) Incorrect. This statement is not accurate and may cause unnecessary concern or confusion for the client.
C) Correct. Adolescents and young adults prescribed with antidepressant medications should be informed about the potential increased risk of suicidal thoughts or behaviors, especially in the early stages of treatment. This information is important for the client's safety and allows for appropriate monitoring.
D) Incorrect. Doubling the dose if a dose is missed is not a safe or appropriate practice. The client should be instructed on what to do if they miss a dose according to their healthcare provider's instructions.
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