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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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Correct Answer is C

Explanation

A. "Dwelling on these struggles will not help you move past your loss.": This response dismisses the client’s feelings and may minimize their grief. Acknowledging their emotions is important for therapeutic communication, and telling the client to stop dwelling may feel invalidating.

B. "Everyone struggles with loss, but you'll be okay in time.": While this response is intended to offer comfort, it may sound dismissive and could undermine the client’s grief experience. Each person processes loss differently, and it's important to acknowledge their feelings.

C. "Attending a support group may help both you and your partner.": This response is supportive and practical. It acknowledges that grief affects both individuals in a relationship and suggests a helpful resource. Support groups provide validation and connection with others going through similar experiences.

D. "Spend more time focusing on your relationship with your partner.": This response oversimplifies the situation and does not acknowledge the depth of the client’s grief. It may feel directive and might not address the underlying emotional need.

A. Genitourinary assessment B. Client's recent loss C. Smoking history D. Client's recent consumption of alcohol

Correct Answer is ["B","D","E","G","H"]

Explanation

Rationale for correct choices:

Client's recent loss: The recent death of the client's parents is a critical factor in the client's relapse into alcohol use. This significant emotional stress can exacerbate substance use and affect the client's mental and physical health, requiring close monitoring and support.
Client's recent consumption of alcohol: The client's last drink was estimated to be 2 hours ago, and they are currently intoxicated with a blood alcohol level (BAC) of 310 mg/dL. This level is dangerously high, requiring immediate observation for signs of alcohol toxicity.
Gastrointestinal assessment: The client reports weight loss and minimal appetite, which may be indicative of alcohol-related damage to the gastrointestinal system, such as gastritis or liver disease. This warrants a thorough assessment to address any underlying issues.
Neurological assessment: The client is intoxicated and has slurred speech, indicating impaired neurological functioning. Additionally, alcohol use disorder can lead to long-term neurological impairments, such as cognitive deficits, which require careful monitoring during withdrawal.
Blood alcohol level: A blood alcohol level of 310 mg/dL is critically elevated and requires urgent follow-up. This level is significantly above the normal range and indicates severe intoxication, which can lead to life-threatening complications such as respiratory depression or coma.

Rationale for incorrect choices:

Genitourinary assessment: There are no immediate concerns related to the client's genitourinary system based on the provided information. The client did not report any issues or symptoms in this area.
Smoking history: Although smoking history is important in overall health assessments, the client's current concerns (alcohol use disorder, recent loss, intoxication) take priority over the 20 years ago smoking history in this situation.
Respiratory assessment: The client's respiratory rate is 10/min, which is low but not immediately alarming in the context of alcohol intoxication. Close monitoring is required, but there is no urgent indication of respiratory distress at this time. The client ‘s respiratory examination is normal as well as SPO2.
Cardiac assessment: The client's heart rate and blood pressure are within normal limits, and there is no indication of acute cardiac distress. Therefore, a cardiac assessment does not require immediate follow-up unless other symptoms develop.

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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

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A nurse is caring for a client who lost their child 6 months ago. The client states, "Not only do I miss my child, but I also feel so distant from my partner." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder, which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["B","D","E","G","H"]

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.