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 C
Explanation
Choice A reason: Cautioning the client against feeling angry at the deceased sibling could invalidate the client's natural grieving process. Anger is a common and expected emotion in the stages of grief, and acknowledging it can be therapeutic. It is important for the nurse to provide a safe space for the client to express all emotions related to their loss.
Choice B reason: Recommending more solitary activities might not be beneficial for a client experiencing depression after a significant loss. Social support and engagement in social activities can be crucial for recovery. Isolation can exacerbate feelings of loneliness and depression. Instead, the nurse should encourage the client to maintain connections with supportive friends and family members.
Choice C reason: Explaining that the duration of grief is highly variable and can last for years is important. Grief does not have a set timeline, and individuals experience it differently. Providing this information can help normalize the client's feelings and reassure them that what they are experiencing is a part of the healing process.
Choice D reason: Encouraging the client to avoid discussing the events surrounding the sibling's death can hinder the grieving process. Open communication about the loss and the associated emotions is essential for healing. The nurse should encourage the client to share their feelings and memories when they feel ready, as this can be a part of the therapeutic process.
Correct Answer is B
Explanation
Choice A reason: This response may seem dismissive and could minimize the client's feelings. It's important to acknowledge the client's emotions as valid and unique to their experience, rather than comparing them to others.
Choice B reason: This response invites the client to share their feelings in a non-judgmental space and shows the nurse's willingness to listen. It respects the client's autonomy and provides an opportunity for them to open up about their concerns at their own pace.
Choice C reason: While this response is meant to be reassuring, it may inadvertently invalidate the client's feelings. Embarrassment is a personal emotion, and what might seem trivial to one person can be significant to another.
Choice D reason: This response implies that sharing will lead to relief, which may not always be the case. It also puts pressure on the client to disclose information before they are ready, which could be counterproductive.
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