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 B

Explanation

A. Muscle aches: Muscle aches can occur during alcohol withdrawal but are not a hallmark finding of this condition. These aches may be present due to general discomfort, anxiety, or tension experienced during withdrawal, but they lack the severity and specificity of other withdrawal symptoms, making them less indicative of the withdrawal syndrome.
B. Hallucinations: Hallucinations are a significant finding in alcohol withdrawal and can manifest as auditory, visual, or tactile disturbances. These symptoms are particularly associated with severe withdrawal and indicate the possibility of alcohol withdrawal delirium, which is a medical emergency requiring prompt intervention and monitoring.
C. Respiratory depression: Respiratory depression is not typically associated with alcohol withdrawal. It may occur in cases of severe intoxication or when alcohol is combined with other central nervous system depressants like opioids, but it is not a direct consequence of withdrawal symptoms, which primarily involve autonomic instability and cognitive disturbances.
D. Decreased blood pressure: While some individuals may experience changes in blood pressure during alcohol withdrawal, significant hypotension is not a characteristic finding of this condition. In fact, withdrawal is more commonly associated with increased blood pressure and heart rate due to autonomic instability, reflecting the body's heightened stress response to the absence of alcohol.

A. Evaluation B. Planning C. Assessment D. Implementation

Correct Answer is C

Explanation

A. Evaluation: Evaluation is the phase where the nurse assesses the effectiveness of the interventions and determines if the desired outcomes have been achieved. This phase occurs after interventions have been implemented, not during an interview.
B. Planning: Planning involves setting goals and determining the appropriate interventions for the client's care. While important, it occurs after the assessment phase and is not the stage for conducting interviews about family history.
C. Assessment: The assessment phase involves gathering comprehensive data about the client, including their history, symptoms, and family background. Interviewing the client about their family history of schizophrenia fits this phase as it aims to collect relevant information for understanding the client's condition.
D. Implementation: Implementation refers to the actual execution of the planned interventions. This phase follows assessment and planning, making it an inappropriate time for gathering family history information.

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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

A nurse is preparing a presentation about alcohol withdrawal. Which of the following findings should the nurse include in the presentation?

Correct Answer is B

Explanation

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

Correct Answer is C

Explanation

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A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as a comorbidity to this condition?

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.