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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Respiratory depression and a comatose state are not typically associated with agranulocytosis.
Choice B rationale:
Agranulocytosis, a potential side effect of clozapine, can cause symptoms like a sore throat and muscle aches due to the body’s decreased ability to fight off infections.
Choice C rationale:
Increased anxiety and suicidal ideations are not typically symptoms of agranulocytosis.
Choice D rationale:
Severe restlessness is not a common symptom of agranulocytosis.
Correct Answer is D
Explanation
Choice A rationale:
A BUN of 22 mg/dL is slightly elevated but not a contraindication for clozapine.
Choice B rationale:
A serum potassium of 3.3 mEq/L is slightly low but not a contraindication for clozapine.
Choice C rationale:
A hematocrit of 55% is high but not a contraindication for clozapine.
Choice D rationale:
A WBC of 2,900 cells/mm² is low and can indicate agranulocytosis, a potentially life-threatening condition. Clozapine should be discontinued.
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