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.
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Related Questions
Correct Answer is B
Explanation
A) Incorrect. While kidney function is important for overall health, it is not the primary focus for ruling out medical conditions contributing to major depressive disorder.
B) Correct. Thyroid function can significantly impact mood and energy levels. Abnormalities in thyroid function can sometimes present with symptoms similar to depression, so a thyroid panel (including TSH, T3, and T4 levels) is an important test to consider.
C) Incorrect. While liver function is important for overall health, it is not the primary focus for ruling out medical conditions contributing to major depressive disorder.
D) Incorrect. A urinalysis with culture is not a standard test for ruling out medical conditions contributing to major depressive disorder. It is more relevant for assessing urinary tract infections or kidney function.
Correct Answer is ["A","D","F"]
Explanation
A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.
B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.
C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.
D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.
E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.
F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.
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