A nurse is collecting data from a client who has a new diagnosis of schizophrenia.
Which of the following client statements supports this diagnosis?

"I just need a couple of hours of sleep each night.”.

"Remembering where I put things has become difficult.”.

"I won't eat because I know that the food has been poisoned.”.

"Counting stairs helps me feel more in control.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A need for only a couple of hours of sleep each night could suggest mania, a symptom associated with bipolar disorder, rather than schizophrenia. Individuals with schizophrenia often experience sleep disturbances, but this specific statement is more indicative of a manic episode.

Choice B rationale

Difficulty remembering where things are placed can be a symptom of various conditions, including normal aging, stress, depression, or cognitive impairments. While cognitive deficits can occur in schizophrenia, this statement alone is not a strong indicator of the disorder's core features.

Choice C rationale

The statement "I won't eat because I know that the food has been poisoned" is a paranoid delusion, a positive symptom commonly seen in schizophrenia. Delusions are fixed, false beliefs that are not based in reality and are a hallmark feature of psychotic disorders like schizophrenia.

Choice D rationale

Counting stairs to feel more in control could be a mild compulsion or a coping mechanism for anxiety. While anxiety can co-occur with schizophrenia, this behavior itself is not a primary diagnostic criterion for the disorder.

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Correct Answer is A

Explanation

Choice A rationale

"Tell me about your baby. Where is she now?" is the priority response because it immediately assesses the safety and well-being of the baby. The mother's statement suggests potential distress and inability to cope, raising concerns about the infant's care.

Choice B rationale

"Do you have a friend who could help you?" explores the client's support system, which is important but secondary to ensuring the immediate safety of the baby.

Choice C rationale

"Having a newborn must be stressful" is an empathetic statement that acknowledges the client's feelings. While therapeutic, it does not address the potential immediate needs and safety of the baby.

Choice D rationale

"Do you have other children?" gathers information about the client's family situation, but it is not the priority when there is a potential concern about the well-being of the newborn. .

A. Implement 24-hr one-to-one nursing observation. B. Restrict interactions with other clients. C. Document the client's behavior every 2 hr. D. Administer prescribed medication via the IM route.

Correct Answer is A

Explanation

Choice A rationale

Implementing 24-hr one-to-one nursing observation is a necessary precaution for a newly admitted adolescent who overdosed on prescription pain medication. This close monitoring allows for continuous assessment of the client's physical and mental status, early detection of any complications, and prevention of further self-harm attempts, especially given the prescriptions for an anxiolytic and an SSRI, which could have delayed or paradoxical effects in an overdose situation.

Choice B rationale

Restricting interactions with other clients might increase the adolescent's feelings of isolation and depression, which could be counterproductive to their mental health recovery. Therapeutic interactions with peers can be beneficial.

Choice C rationale

Documenting the client's behavior every 2 hr is a standard nursing practice, but it is not sufficient for a client at high risk for self-harm following an overdose. Continuous observation provides immediate intervention capability.

Choice D rationale

Administering prescribed medication via the IM route is not necessarily a standard precaution for an overdose. The route of administration depends on the specific medication and the client's condition. Oral administration is usually preferred when the client is stable and can tolerate it.

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A nurse is collecting data from a client who has a new diagnosis of schizophrenia.Which of the following client statements supports this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is collecting data from a client who has a new diagnosis of schizophrenia.
Which of the following client statements supports this diagnosis?