A nurse is caring for a client who has schizophrenia.

Exhibits

The nurse is reviewing the client's medical record.

Select the "3" findings that require immediate follow-up by the nurse.

Blood pressure

Hallucinations

Insomnia

Delusions

Appetite

Answer and Explanation

Correct Answer : A,B,C

A. Blood pressure: The client's blood pressure has increased significantly from 132/68 mm Hg to 156/92 mm Hg. This elevation may indicate a physiological response to anxiety or agitation and requires monitoring and assessment for potential cardiovascular issues.
B. Hallucinations: The client reports auditory hallucinations ("the voices are coming back") and visual hallucinations (seeing a man in the corner of the room). These symptoms indicate a need for immediate intervention and further evaluation to ensure the client's safety and address their psychotic symptoms.
C. Insomnia: The client states they cannot sleep, which is a significant concern as lack of sleep can exacerbate psychiatric symptoms, impair functioning, and increase the risk of self-harm or harm to others. Addressing sleep disturbances is critical for the client's overall treatment and well-being.
D. Delusions: While delusions (e.g., believing that people are trying to hurt the client) are concerning and require monitoring, the hallucinations reported by the client are more acute and pose a more immediate risk to the client's safety. Therefore, hallucinations take priority over delusions in this situation.
E. Appetite: The client consumed 50% of their evening meal, which indicates some level of appetite. Although changes in appetite can be relevant in the context of mental health, it is not as urgent as the other findings related to blood pressure, hallucinations, and insomnia, which directly impact the client's immediate safety and well-being.

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Correct Answer is C

Explanation

A. Restrict calories to maintain weight: Restricting calories is not a recommended practice during pregnancy. Adequate nutrition is essential for the health of both the mother and the developing baby, and weight management should be approached with a focus on healthy eating rather than calorie restriction.
B. Abstain from getting pregnant until later in life: While age can be a factor in the risk of certain conditions, there is no definitive evidence that waiting to become pregnant significantly reduces the risk of the baby developing schizophrenia. The focus should be on overall health and prenatal care rather than solely on age.
C. Avoid contracting a viral infection: Certain viral infections during pregnancy, particularly in the first and second trimesters, may increase the risk of developmental disorders, including schizophrenia. Therefore, taking precautions to avoid infections (such as practicing good hygiene and getting vaccinations) is a relevant recommendation for reducing potential risks.
D. Limit iron intake: Adequate iron intake is important during pregnancy to support both the mother’s health and the baby’s development. Limiting iron is not advisable and could lead to anemia or other complications during pregnancy.

A. "Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning." B. "Were you avoiding your friend so that you could hear the voices more clearly?" C. "That is very interesting. We are not sure why people start to isolate themselves." D. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize."

Correct Answer is A

Explanation

A. "Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning.": This response provides an accurate explanation of a common behavior associated with the early stages of schizophrenia. It normalizes the client's experience by indicating that social withdrawal can be an early warning sign of developing symptoms, helping the client understand their condition better.
B. "Were you avoiding your friend so that you could hear the voices more clearly?": This response may come across as accusatory and could increase the client's anxiety or defensiveness. It does not promote a supportive dialogue about the client's experience and symptoms.
C. "That is very interesting. We are not sure why people start to isolate themselves.": While acknowledging the client's comment, this response lacks helpful information and does not provide insight into the relationship between isolation and the onset of schizophrenia symptoms. It misses an opportunity to educate the client about their condition.
D. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize.": This question may divert the conversation from the client's experience with schizophrenia to a discussion about personality traits. It does not directly address the client's concern about isolation and the onset of their symptoms, making it less relevant to the situation.

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A nurse is caring for a client who has schizophrenia. Exhibits The nurse is reviewing the client's medical record. Select the "3" findings that require immediate follow-up by the nurse.

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Explanation

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Explanation

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A nurse is caring for a client who has schizophrenia. Exhibits Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.

A nurse is caring for a client who has schizophrenia.

Exhibits

The nurse is reviewing the client's medical record.

Select the "3" findings that require immediate follow-up by the nurse.