A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?
Isolate the client from other clients.
Administer a PRN sedative.
Escort the client to a private area.
Avoid recognizing the behavior.
The Correct Answer is C
A. Isolating the client might exacerbate feelings of social exclusion and isn't the best approach for managing echolalia.
B. Administering a sedative should not be the initial response to echolalia unless the behavior poses immediate harm to the client or others.
C. Escorting the client to a private area can help reduce the annoyance to other clients without isolating or punishing the individual.
D. Avoiding recognition of the behavior doesn't address the issue and might negatively impact the therapeutic relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Familial history of mental illness is important but might not directly impact the initiation of sertraline treatment.
B. Medication history is the most important information to obtain before starting sertraline. This includes any current medications the client is taking, especially other antidepressants, anticoagulants, or medications that may interact with sertraline. Sertraline is a selective serotonin reuptake inhibitor (SSRI), and it can interact with other medications, such as monoamine oxidase inhibitors (MAOIs) or other serotonergic drugs, leading to serious side effects like serotonin syndrome.
C. While current weight may be important for monitoring side effects such as weight gain, it is not as immediately critical as understanding the client’s medication history, particularly regarding potential drug interactions.
D. A history of heart disease is relevant to the overall health assessment, but sertraline is generally considered safe for most individuals with heart disease. However, the medication history is more crucial because of potential drug interactions.
Correct Answer is D
Explanation
A. Vomiting, seizures, and loss of consciousness are severe manifestations but not commonly associated with narcotic withdrawal.
B. Depression, fatigue, and dizziness are symptoms commonly associated with depression but not specifically with narcotic withdrawal.
C. Hypotension, shallow respirations, and dilated pupils are more indicative of opioid overdose rather than withdrawal.
D. Agitation, sweating, and abdominal cramps are common symptoms of narcotic withdrawal.
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