A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?

Anticipate the behavior and restrain when pacing begins.

Assess environmental triggers and potential unmet needs.

Assess for potential injury.

Consult the psychologist regarding behavior modification techniques.

Answer and Explanation

The Correct Answer is B

a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.

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Correct Answer is B

Explanation

a. Psychotic disorder: Schizophrenia is a well-defined psychotic disorder characterized by delusions, hallucinations, and disorganized thinking, but it doesn't specifically address the mood component present in this case.
b. Schizoaffective disorder: Schizoaffective disorder is characterized by symptoms of both schizophrenia (such as delusions and hallucinations) and mood disorders (such as depression or mania). The presence of delusional thinking and visual hallucinations, combined with periods of depression and suicidal ideations, fits the profile of schizoaffective disorder.
c. Paranoid disorder: Paranoid disorder is characterized by a pervasive pattern of suspicion and distrust, but it doesn't necessarily involve hallucinations or disorganized thinking like schizophrenia.
d. Schizophreniform disorder: Schizophreniform disorder is similar to schizophrenia but with a shorter duration of symptoms (less than 6 months). The prompt doesn't specify the duration, making schizophrenia a more likely diagnosis.

A. "I am less likely to get an infection while taking this medication." B. "Weight loss is a sign that my medication dose is too low." C. "I will contact my healthcare provider if I have difficulty urinating." D. "I will stop taking this medication once my hallucinations go away."

Correct Answer is C

Explanation

a. "I am less likely to get an infection while taking this medication." This statement is incorrect. Chlorpromazine can actually increase the risk of infection due to potential side effects like agranulocytosis (a drop in white blood cell count).
b. "Weight loss is a sign that my medication dose is too low." This statement is incorrect. Chlorpromazine typically causes weight gain rather than weight loss.
c. "I will contact my healthcare provider if I have difficulty urinating." This statement indicates an understanding of one of the potential side effects of chlorpromazine, which can cause urinary retention due to its anticholinergic properties.
d. "I will stop taking this medication once my hallucinations go away." This statement is incorrect. Discontinuing antipsychotic medication without a healthcare provider's guidance can lead to a relapse of symptoms.

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A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a schizophrenic client who is exhibiting delusional thinking, visual hallucinations, suicidal ideations, and periods of depression. The nurse would recognize that the client is displaying which category of schizophrenia?

Correct Answer is B

Explanation

A client with schizophrenia is receiving teaching from the nurse about their prescribed medication, Chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia disorder, tells them that voices command the child to harm others. Which is the appropriate nursing response?

Which of the following will the nurse use when communicating with a client who has a cognitive disorder?