A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.

Which of the following is the priority nursing intervention for this client?

Ensure the client goes to group activities as planned.

Use distraction such as the television or music.

Provide reassurance and comfort ensuring the client is safe.

Give PRN medications to treat increased hallucinations.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.

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Correct Answer is B

Explanation

Choice A rationale:

Asking why the client feels they will never get better might come across as dismissive or confrontational.

Choice B rationale:

This response acknowledges the client’s feelings and offers a supportive approach to managing the symptoms of somatic symptom disorder. This disorder is characterized by a significant focus on physical symptoms that cause major distress and/or problems functioning. The main treatment is psychotherapy, and medication might be given in some cases.

Choice C rationale:

Focusing only on the physical symptoms might not address the emotional distress that the client is experiencing.

Choice D rationale:

While it’s important to offer hope, this response might come across as dismissive of the client’s current feelings.

A. The lithium level is within the therapeutic level for initial treatment. B. The lithium level is below the therapeutic treatment level. C. The lithium level is at the toxic level. D. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level.

Correct Answer is C

Explanation

Choice A rationale:

A lithium level of 1.8 mEq/L is above the therapeutic level for initial treatment (0.8 to 1.4 mEq/L)3.

Choice B rationale:

A lithium level of 1.8 mEq/L is above, not below, the therapeutic treatment level.

Choice C rationale:

A lithium level of 1.8 mEq/L is at the toxic level. A blood lithium level greater than 1.5 mEq/L indicates toxicity.

Choice D rationale:

A lithium level of 1.8 mEq/L is not within the maintenance treatment level (0.4 to 1.3 mEq/L)3.

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A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns. Which of the following is the priority nursing intervention for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse, "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better.”. Which of the following responses is the most therapeutic?

Correct Answer is B

Explanation

A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following?.

Correct Answer is C

Explanation

Your patient is experiencing extrapyramidal symptoms (EPS) from antipsychotic therapy. You understand that the following medications are used to reverse EPS. (Select All that Apply.).

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

A nurse is caring for a client in an outpatient clinic. Exhibits The nurse should identify which of the following findings as manifestations of somatic symptom disorder? (Select all that apply.).

A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.

Which of the following is the priority nursing intervention for this client?