A client diagnosed with schizophrenia disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop the psychiatrist." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?
Altered thought processes; call an emergency treatment team meeting.
Command hallucinations; warn the psychiatrist.
Persecutory delusions; orient the client to reality.
Magical thinking; administer an antipsychotic medication.
The Correct Answer is B
a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. The unit can be managed with fewer staff. Seclusion requires close monitoring by staff.
b. Clients are encouraged to communicate with others. Seclusion is meant to be a temporary measure to prevent further harm, not necessarily to promote communication.
c. The reduced sensory input allows the client to regain control. Seclusion is a time-limited safety intervention used when a client poses a danger to themselves or others. It provides a safe space with reduced stimulation to allow the client to calm down and regain control.
d. Clients are forced to be responsible for themselves. Seclusion is not a punitive measure. The goal is to ensure safety and facilitate regaining control.
Correct Answer is D
Explanation
a. Hypoglycaemia can occur, but it is not as immediately life-threatening as cardiac dysrhythmia.
b. Endocrine imbalance and amenorrhea are significant but not usually immediately life-threatening.
c. Cold intolerance due to decreased metabolism is uncomfortable but not immediately life-threatening.
d. Cardiac dysrhythmias are a major health complication of anorexia nervosa due to electrolyte imbalances, particularly hypokalaemia, which can lead to cardiac arrest. This is a life-threatening condition that needs to be monitored closely.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.