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 B
Explanation
A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.
B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.
C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.
D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.
Correct Answer is ["10"]
Explanation
Dose (mL) = Desired dose (mg) / Available dose (mg/mL) Plugging in the values from the question, we get:
Dose (mL) = 80 mg / (40 mg / 5 mL) Simplifying the fraction, we get:
Dose (mL) = 80 mg / 8 mg/mL Dividing both sides by 8, we get:
Dose (mL) = 10 mL
Therefore, the nurse should administer 10 mL of fluoxetine per dose.
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