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 A

Explanation

A. “I have lost 15 pounds! I just don’t want to eat lately.”: Significant weight loss and a loss of appetite can indicate the development of a substance use disorder, as these symptoms may reflect the prioritization of alcohol consumption over proper nutrition. The client’s decreased interest in eating raises concerns about potential alcohol misuse or dependence.
B. “I have been hanging out with friends who are my support system.”: Engaging with a supportive social network is generally a positive indicator and can assist in recovery. Having supportive friends does not indicate a substance use disorder and may even help the client address their drinking behavior.
C. “I am so focused right now. I have a lot of goals.”: A focused and ambitious mindset reflects a positive attitude towards life and managing responsibilities. This perspective does not suggest substance use disorder and may indicate effective coping and life management, despite issues with alcohol.
D. “I am taking art lessons to relieve stress.”: Participating in art lessons demonstrates a constructive approach to managing stress through creativity. This behavior indicates healthy coping mechanisms and does not suggest a substance use disorder.

A. Dissociative amnesia B. Factitious disorder C. Illness anxiety disorder D. Functional neurological symptom disorder

Correct Answer is B

Explanation

A. Dissociative amnesia: This diagnosis involves a loss of memory for personal information or events, typically following trauma or stress. It does not relate to intentionally causing injuries or symptoms.
B. Factitious disorder: Individuals with factitious disorder intentionally produce or feign physical or psychological symptoms to assume the role of a sick person. This behavior can include causing self-harm, such as breaking bones, to gain attention, sympathy, or care from others. The client's actions align with this diagnosis.
C. Illness anxiety disorder: Previously known as hypochondriasis, this disorder involves excessive worry about having a serious illness despite having no significant medical evidence. Individuals with this disorder do not intentionally cause harm to themselves; rather, they focus on perceived health concerns.
D. Functional neurological symptom disorder: This disorder involves neurological symptoms that cannot be explained by medical conditions. While individuals may have genuine neurological symptoms, they do not typically engage in self-harm or intentionally inflict injuries as seen in factitious disorder.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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.