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A nurse is caring for a client who has schizophrenia and is preparing for discharge.

Exhibits

The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

Ask a trusted person to watch for manifestations of illness.

Notify your provider within 48 hr of manifestations of a relapse.

Go for a walk to decrease anxiety during times of increased stress.

Report any adverse effects of the medication to the provider immediately.

Limit alcohol consumption to no more than two drinks per week.

Take a dose of the medication as soon as delusions or hallucinations begin.

Answer and Explanation

Correct Answer : A,B,C,D

Rationale for correct choices:

Ask a trusted person to watch for manifestations of illness: Involving a trusted person in monitoring symptoms can help identify early signs of relapse. Sometimes, clients may not notice subtle changes in their mental state, so a reliable individual can alert the healthcare provider, allowing for early intervention.
Notify your provider within 48 hr of manifestations of a relapse: Early detection and intervention are key to preventing a full relapse. By notifying the provider within 48 hours, the healthcare team can adjust medications or other interventions promptly, reducing the severity of symptoms.
Go for a walk to decrease anxiety during times of increased stress: Physical activity, like walking, is beneficial for managing anxiety, which is a common trigger in individuals with schizophrenia. Regular exercise can also promote mental well-being, making it a helpful strategy for coping with stress.
Report any adverse effects of the medication to the provider immediately: Antipsychotic medications like haloperidol can cause significant side effects, and reporting these early allows the provider to manage or adjust the treatment plan, preventing complications such as extrapyramidal symptoms or neuroleptic malignant syndrome.

Rationale for incorrect choices:

Limit alcohol consumption to no more than two drinks per week: Alcohol should be avoided entirely, as it can interfere with the effectiveness of antipsychotic medications and worsen psychiatric symptoms.
Take a dose of the medication as soon as delusions or hallucinations begin: Medications for schizophrenia, like haloperidol, should be taken as prescribed, and adjustments to dosage or frequency should only be made under the guidance of a healthcare provider.

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Free Nursing Study Resources

Correct Answer is ["B","E","F","G"]

Explanation

Rationale for correct choices:

Offer emergency contraception: In cases of sexual assault, emergency contraception should be offered as soon as possible to prevent pregnancy. This is a standard part of care for survivors of sexual violence, ideally within 72 hours after the assault.
Collect and preserve evidence: Collecting and preserving physical evidence is critical for legal and forensic purposes. This includes clothing, swabs, and other materials that may help in a potential investigation. The nurse should follow proper protocols to ensure evidence is preserved without contamination.
Administer sexually transmitted infection prophylaxis: Given the risk of sexually transmitted infections (STIs) following sexual assault, prophylaxis should be provided immediately, especially for high-risk infections such as chlamydia, gonorrhea, and HIV.
Document the assessment findings in written and photographic form: Proper documentation of the client's physical findings, including bruising, broken fingernails, and other injuries, is essential for both legal purposes and ongoing medical care.

Rationale for incorrect choices:

Allow the client to shower prior to their genital examination: The client should not be allowed to shower or change clothes before the genital examination or evidence collection, as this could wash away important forensic evidence, such as bodily fluids or hair.
Initiate a prescription for an antidepressant: While it is important to offer psychological support and follow-up care, prescribing an antidepressant should not be the immediate action. The client may require further assessment by a mental health professional to determine the most appropriate treatment.
Perform a rapid HIV test: While HIV exposure is a concern after sexual assault, a rapid HIV test immediately following an assault will likely be negative as there is an incubation period (window period) before antibodies can be detected. Post-exposure prophylaxis (PEP) for HIV is the more appropriate immediate intervention.

A. "I will learn how to voluntarily control my blood pressure and heart rate” B. "I will focus on a mental image while concentrating on my breathing." C. "I will progressively relax each of my muscle groups when feeling stressed." D. "I will practice replacing negative thoughts with positive self-statements"

Correct Answer is D

Explanation

A. "I will learn how to voluntarily control my blood pressure and heart rate": This statement refers to biofeedback, which focuses on controlling physiological responses like heart rate and blood pressure. It is not part of cognitive reframing, which targets thoughts.

B. "I will focus on a mental image while concentrating on my breathing.": This is describing guided imagery and relaxation techniques. While these are effective stress management strategies, they are not part of cognitive reframing, which focuses on altering negative thought patterns.

C. "I will progressively relax each of my muscle groups when feeling stressed.": This statement refers to progressive muscle relaxation, which helps with physical relaxation but does not involve changing thought patterns.

D. "I will practice replacing negative thoughts with positive self-statements": This is an accurate description of cognitive reframing. It involves identifying negative thoughts and replacing them with more balanced or positive ones to manage stress and improve emotional well-being.

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A nurse is caring for a client who has schizophrenia and is preparing for discharge. Exhibits The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["B","E","F","G"]

Explanation

A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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A nurse is caring for a client who has schizophrenia and is preparing for discharge.

Exhibits

The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.