A nurse in a mental health facility is caring for a client who is readmitted for schizophrenia after 2 weeks following the previous discharge. The nurse notices that the client's appearance is unkempt and the client is mumbling to himself constantly. Which of the following assessments is the nurse's priority?
Physical health needs
Mental status
Anxiety level
Perception of reality
The Correct Answer is A
Choice A reason: Physical health needs are always the priority in nursing care. Clients with schizophrenia may neglect hygiene, nutrition, or medical conditions due to impaired functioning. Addressing physical health ensures safety and stability before focusing on psychological needs.
Choice B reason: Assessing mental status is important but comes after ensuring physical health. Mental status evaluation helps guide psychiatric treatment but is not the immediate priority.
Choice C reason: Anxiety level assessment is useful but secondary. Anxiety may contribute to symptoms, but it does not outweigh the need to stabilize physical health.
Choice D reason: Perception of reality is essential for psychiatric evaluation, but it is not the first priority. Physical health must be stabilized before addressing psychotic symptoms.
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Correct Answer is B
Explanation
Choice A reason: This response dismisses the client’s delusion and does not provide therapeutic support. Minimizing the client’s concern can increase mistrust and resistance to treatment.
Choice B reason: This is the correct response because it acknowledges the client’s concern without validating the delusion. It also encourages participation in therapy by offering support and companionship. This approach is therapeutic and helps redirect the client’s focus.
Choice C reason: While encouraging therapy attendance is appropriate, this response does not address the client’s immediate concern and may come across as dismissive. It lacks the supportive element of walking with the client.
Choice D reason: Asking the client to explain the delusion can reinforce it and is not therapeutic. Nurses should avoid challenging or confronting delusions directly, as this can increase defensiveness and agitation.
Correct Answer is C
Explanation
Choice A reason: Anhedonia, or the inability to experience pleasure, is considered a negative symptom of schizophrenia. Negative symptoms reflect a loss of normal functioning, such as reduced emotional expression or social withdrawal, rather than the presence of abnormal behaviors.
Choice B reason: Dysphoria refers to a state of unease or dissatisfaction, often associated with mood disorders. While individuals with schizophrenia may experience dysphoria, it is not classified as a positive symptom.
Choice C reason: Disorganized speech is a hallmark positive symptom of schizophrenia. Positive symptoms are characterized by the presence of abnormal behaviors, such as hallucinations, delusions, and disorganized thinking. Disorganized speech reflects thought disorder, where the client’s communication is fragmented, illogical, or incoherent.
Choice D reason: Impaired judgment is a cognitive deficit that can occur in schizophrenia but is not categorized as a positive symptom. It reflects difficulties in decision-making and problem-solving rather than abnormal additions to behavior.
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