A nurse is assisting in the care of a client who was brought to the emergency department by the police

Select the 4 client findings from the Nurses' Notes that indicate psychosis.

Response to stimuli

Affect

Thought process

Level of orientation

Speech pattern

Physical appearance

Answer and Explanation

Correct Answer : A,C,D,F

A. Response to stimuli: The client was responding to internal stimuli, such as hearing helicopters and believing they are being pursued. Responding to hallucinations is a hallmark sign of psychosis.

B. Affect: Affect refers to the observable expression of emotion. While the client’s agitation and cooperation may be noted, affect alone does not confirm psychosis without evidence of altered perception or thought content.

C. Thought process: The client exhibits disorganized and paranoid thoughts, such as believing the clinic is a laboratory and the nurse is the devil. These delusions indicate impaired thought processes associated with psychosis.

D. Level of orientation: The client is able to state their name but not the date and misinterprets surroundings, demonstrating disorientation and impaired reality testing, which are consistent with psychosis.

E. Speech pattern: The notes do not specifically describe incoherence, flight of ideas, or pressured speech. While speech may reflect agitation, it is not explicitly documented as psychotic.

F. Physical appearance: The client appears disheveled with matted hair and stained clothing, reflecting neglect of self-care, which is often observed in clients experiencing psychosis.

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Correct Answer is D

Explanation

A. Hypertension: Hyponatremia typically does not cause high blood pressure. In fact, low sodium levels can lead to fluid shifts and hypotension in severe cases, rather than hypertension. Monitoring blood pressure is important, but hypertension is not an expected finding of hyponatremia.

B. Blurred vision: Blurred vision is not a classic symptom of hyponatremia. While severe electrolyte imbalances can affect neurological function, visual changes are more commonly associated with hypernatremia or other conditions affecting the eyes.

C. Constipation: Constipation is not directly linked to low sodium levels. Hyponatremia primarily affects neuromuscular and neurological function, rather than gastrointestinal motility.

D. Muscle cramps: Muscle cramps are a common manifestation of hyponatremia due to the disruption of sodium’s role in neuromuscular excitability. Low sodium levels can cause involuntary muscle contractions, weakness, and twitching.

A. Introduce self and set goals for the relationship. B. Examine personal thoughts and feelings about meeting the client. C. Summarize the achievement of goals that have been met. D. Assist the client with identifying problem-solving techniques,

Correct Answer is B,A,D,C

Explanation

A. Examine personal thoughts and feelings about meeting the client: The nurse should first engage in self-reflection to identify any biases, anxieties, or expectations. This helps ensure that personal feelings do not interfere with establishing a therapeutic and professional relationship with the client.

B. Introduce self and set goals for the relationship: After self-reflection, the nurse introduces themselves to the client and collaboratively establishes the goals and boundaries of the therapeutic relationship. This step builds trust and sets clear expectations for interactions.

C. Assist the client with identifying problem-solving techniques: Once the relationship is established, the nurse helps the client develop coping and problem-solving strategies. This step supports the client’s growth, autonomy, and ability to manage challenges effectively.

D. Summarize the achievement of goals that have been met: At the conclusion of the therapeutic relationship, the nurse reviews progress with the client and summarizes goals that were achieved. This reinforces accomplishments, encourages continued growth, and provides closure to the relationship.

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A nurse is assisting in the care of a client who was brought to the emergency department by the police Select the 4 client findings from the Nurses' Notes that indicate psychosis.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Correct Answer is B,A,D,C

Explanation

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A nurse is assisting in the care of a client who was brought to the emergency department by the police

Select the 4 client findings from the Nurses' Notes that indicate psychosis.