A nurse is caring for a client who has schizophrenia.
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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. People diagnosed with schizophrenia are more violent than others: Individuals with schizophrenia are not inherently more violent than the general population. The majority are not violent and are often more likely to be victims rather than perpetrators of violence.
B. Biologically female clients are likely to be diagnosed earlier than biologically born males: Research indicates that biologically male clients often present with symptoms earlier than females.
C. Biologically male clients are typically diagnosed earlier than biologically female clients: Research shows that males tend to exhibit the onset of schizophrenia earlier, usually in late adolescence to early adulthood, whereas females may experience a later onset, often in their 20s or 30s.
D. Diagnosis commonly occurs in individuals under the age of 12: Schizophrenia is rare in children under 12 years of age, and diagnosis typically occurs in late adolescence or early adulthood. Early-onset schizophrenia is uncommon, and most cases are diagnosed after the age of 12.
Correct Answer is D
Explanation
A. The nurse will lose their nursing license immediately: While stealing and taking drugs from the narcotics cart is a serious offense, losing a nursing license typically involves a formal investigation process and a hearing before the board of nursing. Immediate revocation is unlikely without due process.
B. The nurse will need to transfer to a different unit: Transferring to a different unit does not address the underlying issue of substance abuse or theft. While this may occur in some cases, it is not a likely initial outcome given the severity of the allegations.
C. The nurse will be fired immediately: While termination may occur as a consequence of the behavior, it is not the immediate action taken in response to the report. The facility may conduct an investigation before deciding on termination.
D. The nurse will be assisted into drug treatment: It is common for healthcare facilities to offer assistance for substance use disorders, especially if the nurse expresses a willingness to seek help. The initial outcome often includes referrals to treatment programs as part of a broader approach to address the issue and ensure the nurse receives the necessary support.
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