A nurse in a mental health facility is admitting a client who was brought in by the police department.
Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition:
a) Schizophrenia
Choice A reason: Schizophrenia is a chronic mental health condition characterized by symptoms such as delusions, hallucinations, disorganized speech, and significant social or occupational dysfunction. The client’s symptoms, including mumbling as if talking to unseen others and the belief that someone is trying to poison them, are indicative of psychotic features commonly associated with schizophrenia. The prescribed medications, clozapine and risperidone, are antipsychotics often used in the treatment of schizophrenia, further supporting this diagnosis.
Actions to Take:
d) Place the client in a room near the nurses’ station This action allows for close observation and quick intervention if the client’s condition worsens or if they exhibit behaviors that could be harmful to themselves or others.
f) Maintain the client taking their prescribed medications Continuing the prescribed antipsychotic medications is crucial for managing the symptoms of schizophrenia and preventing exacerbation of the condition.
Parameters to Monitor:
j) Command hallucinations Monitoring for command hallucinations is important as they can lead to dangerous behaviors, including harm to self or others, if the client acts on these hallucinations.
l) Suicidal ideation Patients with schizophrenia are at an increased risk for suicide, especially during acute episodes or when experiencing command hallucinations. Regular assessment for suicidal ideation is a critical component of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.
Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.
Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.
Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.
Correct Answer is A
Explanation
Choice A reason: Asking the client about their hallucinations can provide valuable information about the content and nature of the hallucinations. This can help the nurse assess the client's current mental state and the potential impact of the hallucinations on their behavior and safety.
Choice B reason: Focusing the client on reality-based topics is a strategy that can be used after understanding the client's hallucinations. It's important to first acknowledge the client's experience before attempting to redirect their attention.
Choice C reason: Taking the client for a walk may be a good distraction technique, but it should not be the first action. The nurse needs to assess the client's safety and the potential risks associated with the hallucinations before engaging in activities.
Choice D reason: Encouraging the client to listen to music can be a therapeutic intervention to help distract from hallucinations. However, it is not the first action to take. The nurse should first understand the client's experience and ensure their safety.
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