A 30-year-old man is admitted to the mental health inpatient unit diagnosed with schizophrenia.
His clothes are dirty, his hair is unkempt, he hasn’t shaved for several days, and his teeth are chipped with several cavities visible.
He is experiencing hallucinations and delusions.
What is the primary concern for this client?
Inability to engage in self-care activities.
Refusal to participate in self-care activities.
Difficulty in social interactions.
Resistance to medication therapy.
The Correct Answer is A
Choice A rationale
The description of the man’s appearance and behavior suggests that he is struggling with basic self-care activities, such as maintaining personal hygiene and taking care of his physical health. This is a common issue for individuals with schizophrenia.
Choice B rationale
While refusal to participate in self-care activities could be a concern, the information provided doesn’t indicate that the man is refusing to engage in these activities. Rather, it seems he may be unable to do so.
Choice C rationale
Difficulty in social interactions can be a symptom of schizophrenia, but the primary concern in this case, based on the information given, appears to be the man’s inability to engage in self-care activities.
Choice D rationale
Resistance to medication therapy could be a concern for individuals with schizophrenia, but the information provided doesn’t indicate that this is the primary concern in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse’s response of asking the client, “How do you feel about being discharged?” is the most therapeutic. This open-ended question encourages the client to express their feelings and concerns about being discharged. It allows the nurse to assess the client’s readiness for discharge and to provide appropriate education or referrals if needed. It also demonstrates empathy and respect for the client’s feelings, which are key components of a therapeutic relationship.
Choice B rationale
Telling the client, “I will send you a note in a few weeks,” is not the best response. While it may seem like a kind gesture, it could potentially blur the boundaries of the therapeutic relationship. Nurses must maintain professional boundaries with clients to ensure that the focus remains on the client’s needs and not the personal feelings or needs of the nurse.
Choice C rationale
Saying, “I know you will do well living out in the community,” is an assumption and does not invite the client to share their feelings or concerns. It’s important for the nurse to encourage the client to express their feelings about discharge and to provide support and education based on the client’s individual needs.
Choice D rationale
Asking the client, “Aren’t you excited about being discharged today?” is a closed-ended question that assumes the client is excited about discharge. This type of question does not encourage the client to share their feelings or concerns. It’s important for the nurse to use open-ended questions to encourage the client to express their feelings about discharge.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Mutuality involves a shared understanding and agreement between the nurse and the client about the goals and direction of therapy.
Choice B rationale
Caring involves showing kindness, concern, and support for the client.
Choice C rationale
Empathy involves understanding and sharing the feelings of the client.
Choice D rationale
Genuineness involves being open, honest, and authentic in interactions with the client.
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