A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?

Weigh the client daily.

Monitor the client for signs of bleeding.

Monitor the client’s respirations every 4 hours.

Administer an antacid with the medication to decrease nausea.

Answer and Explanation

The Correct Answer is A

Choice A reason: Weigh the client daily is important because chlorpromazine can cause weight gain as a side effect. Regular monitoring of the client’s weight helps in managing and mitigating this potential adverse effect.

Choice B reason: Monitor the client for signs of bleeding is not typically necessary for clients taking chlorpromazine. This medication does not commonly cause bleeding issues. Monitoring for bleeding would be more relevant for clients on anticoagulants or medications that affect platelet function.

Choice C reason: Monitor the client’s respirations every 4 hours is not specifically required for clients on chlorpromazine. While respiratory depression can be a concern with some medications, it is not a common side effect of chlorpromazine.

Choice D reason: Administer an antacid with the medication to decrease nausea is not recommended. Antacids can interfere with the absorption of chlorpromazine, reducing its effectiveness. If the client experiences nausea, other antiemetic strategies should be considered.

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Correct Answer is D

Explanation

Choice A reason: Increased urinary output is not a typical manifestation of peritonitis. Peritonitis, especially in the context of peritoneal dialysis, does not usually affect urinary output directly. Instead, it primarily affects the peritoneal cavity and can lead to symptoms such as abdominal pain and tenderness.

Choice B reason: Hyperactive bowel sounds are not commonly associated with peritonitis. In fact, peritonitis can lead to decreased bowel sounds due to the inflammation and irritation of the peritoneum, which can cause paralytic ileus (a temporary cessation of bowel movements).

Choice C reason: Bradycardia (a slower than normal heart rate) is not a typical symptom of peritonitis. Peritonitis can cause systemic symptoms such as fever and tachycardia (an increased heart rate) due to the body’s inflammatory response to infection.

Choice D reason: Nausea and vomiting are common manifestations of peritonitis. The inflammation of the peritoneum can irritate the gastrointestinal tract, leading to these symptoms. Additionally, peritonitis can cause abdominal pain, tenderness, and distention, which are also associated with nausea and vomiting.

A. I am a prophet of the most high king. B. The voices tell me that I must avoid large crowds. C. I am sure that each problem has only one solution. D. I know that you and the other nurses are trying to poison me.

Correct Answer is C

Explanation

Choice A reason: I am a prophet of the most high king

This statement reflects a delusion, which is a common symptom of schizophrenia. Delusions are false beliefs that are not based in reality. This statement does not indicate concrete thinking but rather a fixed, false belief.

Choice B reason: The voices tell me that I must avoid large crowds

This statement indicates auditory hallucinations, another common symptom of schizophrenia. Hallucinations involve perceiving things that are not present. This statement does not reflect concrete thinking but rather a perceptual disturbance.

Choice C reason: I am sure that each problem has only one solution

This statement reflects concrete thinking, which is characterized by a focus on literal and specific details rather than abstract concepts. Concrete thinking involves a rigid and literal interpretation of information, often seen in individuals with schizophrenia. This statement shows a lack of flexibility in thinking and an inability to consider multiple solutions to a problem.

Choice D reason: I know that you and the other nurses are trying to poison me

This statement reflects paranoia, a type of delusion where the individual believes others are out to harm them. Paranoid delusions are common in schizophrenia but do not indicate concrete thinking.

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A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates concrete thinking?

Correct Answer is C

Explanation

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