A nurse is caring for a client who has schizophrenia and notices changes in the client’s behavior.
Which of the following behaviors is the nurse’s priority to report to the provider?
Meaningless phrases
Refusal to eat
Substance use
Decreased energy level
The Correct Answer is A
Choice A rationale:
Meaningless phrases are a hallmark symptom of schizophrenia and can indicate a worsening of the client's psychosis. This is a significant finding because it suggests that the client's ability to think clearly and communicate effectively is deteriorating.
Prompt reporting to the provider is crucial to ensure timely assessment and intervention, which may include medication adjustments or other therapeutic measures to address the worsening psychosis.
Early intervention is essential to prevent further decline in the client's mental state and to minimize the risk of harm to self or others.
I'll provide detailed rationales for the other choices, even though they are not the priority to report:
Choice B rationale:
Refusal to eat can be a symptom of schizophrenia, but it is not as immediate of a concern as meaningless phrases. It's important to monitor the client's nutritional intake and address any underlying causes of the refusal to eat, but this can typically be managed through nursing interventions without requiring immediate provider notification.
Choice C rationale:
Substance use can exacerbate schizophrenia symptoms and should be addressed, but it is not the priority to report in this scenario. The nurse should assess the client's substance use history and patterns, provide education and counseling on the risks of substance use, and collaborate with the provider to develop a treatment plan that addresses both the schizophrenia and the substance use.
Choice D rationale:
Decreased energy level can be a symptom of schizophrenia, but it is also a common symptom of many other conditions. It's important to assess the client's overall health and identify any potential causes of the decreased energy level, but it is not typically a priority to report to the provider unless it is severe or accompanied by other concerning symptoms
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale:
Having consistent unit routines can provide a sense of stability and predictability, which can be beneficial for a client in the manic phase of bipolar disorder.
Choice B rationale:
Providing a stimulating environment can potentially exacerbate symptoms of mania, making it an inappropriate intervention.
Choice C rationale:
Scheduling daily seclusion times is not typically recommended as it can lead to feelings of isolation.
Choice D rationale:
Discouraging daytime napping can potentially lead to fatigue and worsen symptoms, so it’s not typically recommended.
Correct Answer is D
Explanation
Choice A rationale:
Increased salivation is a common side effect of haloperidol, but it is not the most serious adverse effect that the nurse should monitor for. It can be managed with medications such as anticholinergics, and it often subsides with continued use of haloperidol. Choice B rationale:
Serotonin syndrome is a rare but potentially life-threatening condition that can occur when haloperidol is combined with other medications that increase serotonin levels, such as antidepressants. However, it is not a direct adverse effect of haloperidol itself.
Choice C rationale:
Increased menstrual bleeding is not a known side effect of haloperidol.
Choice D rationale:
Tardive dyskinesia is a serious and potentially irreversible movement disorder that can occur as a long-term side effect of haloperidol and other antipsychotic medications. It is characterized by involuntary, repetitive movements of the face, tongue, and limbs.
The risk of tardive dyskinesia increases with the length of time that a person takes haloperidol and with the dose of the medication.
There is no cure for tardive dyskinesia, but the symptoms can sometimes be managed with medications.
It is important for nurses to monitor patients who are taking haloperidol for signs of tardive dyskinesia, so that the medication can be discontinued if necessary.
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