A client with schizophrenia has had 2 hospitalizations within the past 9 months due to non-adherence to medications and their counseling plan. What measures should the nurse and the mental health treatment team recommend for tertiary prevention? (Select All That Apply)
Recommend the client distance themselves from people who knew them before their diagnosis.
Provide the client with a multi-step written plan to follow if auditory hallucinations occur.
Risperidone as a depot formulation every 2 weeks.
Increase white bread and bananas to help with anticholinergic symptoms.
Assist the client to enroll in a program of assertive community treatment.
Correct Answer : B,C,E
Choice A Reason:
Recommending the client distance themselves from people who knew them before their diagnosis is not a suitable measure for tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness by helping patients manage long-term, complex health problems and injuries. It focuses on improving quality of life and reducing symptoms. Distancing from familiar people could lead to social isolation, which might worsen the client’s condition.
Choice B Reason:
Providing the client with a multi-step written plan to follow if auditory hallucinations occur is a practical measure for tertiary prevention. This plan can help the client manage symptoms effectively and reduce the likelihood of hospitalization. It empowers the client to take control of their symptoms and provides clear steps to follow during a crisis, which can be crucial for maintaining stability.
Choice C Reason:
Risperidone as a depot formulation every 2 weeks is an effective measure for ensuring medication adherence in clients with schizophrenia. Depot formulations are long-acting injections that help maintain consistent medication levels in the body, reducing the risk of relapse due to missed doses. This approach is particularly beneficial for clients who have difficulty adhering to daily oral medication regimens.
Choice D Reason:
Increasing white bread and bananas to help with anticholinergic symptoms is not a recommended measure for managing schizophrenia. While diet can play a role in overall health, there is no evidence to suggest that these specific foods help with anticholinergic symptoms. Anticholinergic symptoms are typically managed with medications and other medical interventions.
Choice E Reason:
Assisting the client to enroll in a program of assertive community treatment (ACT) is a highly effective measure for tertiary prevention. ACT provides comprehensive, community-based psychiatric treatment, rehabilitation, and support to individuals with serious and persistent mental illnesses. This approach helps clients manage their symptoms, adhere to treatment plans, and reduce the risk of hospitalization by providing continuous, personalized care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
Slowed psychomotor activity.
Slowed psychomotor activity is a hallmark of hypoactive delirium. Patients with this type of delirium often exhibit reduced physical movement and slower reaction times. This symptom can make hypoactive delirium more challenging to recognize compared to the more obvious agitation seen in hyperactive delirium.
Choice B Reason:
Impaired attention and concentration.
Impaired attention and concentration are common in all forms of delirium, including hypoactive delirium. Patients may have difficulty focusing, sustaining, or shifting attention, which can significantly impact their ability to engage in daily activities or follow conversations.
Choice C Reason:
Hallucinations and delusions.
While hallucinations and delusions can occur in delirium, they are more commonly associated with hyperactive delirium. Hypoactive delirium is characterized more by withdrawal and decreased responsiveness rather than the presence of hallucinations or delusions.
Choice D Reason:
Decreased alertness or responsiveness.
Decreased alertness or responsiveness is a key feature of hypoactive delirium. Patients may appear drowsy, lethargic, or less responsive to their environment. This can sometimes be mistaken for depression or fatigue, making it crucial to differentiate hypoactive delirium from other conditions.
Choice E Reason:
Agitation and restlessness.
Agitation and restlessness are characteristic of hyperactive delirium, not hypoactive delirium5. In hypoactive delirium, patients are more likely to be withdrawn and less responsive rather than agitated or restless.
Correct Answer is ["A","B","E"]
Explanation
Choice A Reason:
The statement “It is okay to eat dessert with my dinner every night” indicates a need for re-teaching. Diet plays a significant role in the risk of developing Alzheimer’s disease. Consuming high amounts of sugar and unhealthy fats can increase the risk of developing conditions like diabetes and cardiovascular disease, which are linked to a higher risk of Alzheimer’s. A balanced diet, such as the Mediterranean or MIND diet, which emphasizes fruits, vegetables, whole grains, and healthy fats, is recommended to reduce the risk.

Choice B Reason:
The statement “I have less to worry about because I am a female” is incorrect and indicates a need for re-teaching. In fact, women are at a higher risk of developing Alzheimer’s disease compared to men. This increased risk is partly due to women living longer than men, but even after accounting for longevity, women still have a higher incidence of Alzheimer’s. Therefore, it is crucial for females to be aware of their risk and take preventive measures.
Choice C Reason:
The statement “I can speak with my healthcare provider about genetic testing” does not indicate a need for re-teaching. Genetic testing can provide valuable information about one’s risk for Alzheimer’s disease, especially if there is a family history of the condition. While routine genetic testing is not generally recommended for everyone, discussing it with a healthcare provider can help individuals understand their risk and make informed decisions about their health.
Choice D Reason:
The statement “I need to make sure to take my blood pressure medication daily” is correct and does not indicate a need for re-teaching. Controlling blood pressure is crucial in reducing the risk of Alzheimer’s disease. High blood pressure, particularly in midlife, is a significant risk factor for cognitive decline and Alzheimer’s. Therefore, taking blood pressure medication as prescribed is an important preventive measure.
Choice E Reason:
The statement “I do not have time in my schedule to add a daily walk” indicates a need for re-teaching. Regular physical activity is one of the most effective ways to reduce the risk of Alzheimer’s disease. Exercise improves blood flow to the brain, reduces inflammation, and promotes the growth of new brain cells. Incorporating physical activity, such as a daily walk, into one’s routine is essential for maintaining cognitive health and reducing the risk of Alzheimer’s.
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