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?

Implementation

Evaluation

Assessment

Planning

Answer and Explanation

The Correct Answer is C

Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.

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Correct Answer is D

Explanation

Choice A reason:
Fasting blood glucose of 120 mg/dL is slightly elevated but does not contraindicate the use of chlorpromazine. This medication is primarily contraindicated in conditions that affect the central nervous system, cardiovascular system, or blood cell counts. Elevated blood glucose levels should be monitored, but they do not pose an immediate risk when starting chlorpromazine.

Choice B reason:
Hypertension is a condition that requires careful monitoring when a patient is on chlorpromazine, but it is not an absolute contraindication. Chlorpromazine can cause orthostatic hypotension, so blood pressure should be monitored regularly. However, hypertension alone does not prevent the use of this medication.

Choice C reason:
Asthma is not a contraindication for chlorpromazine. While respiratory conditions should be monitored, chlorpromazine does not have a direct adverse effect on asthma. The primary concerns with chlorpromazine involve its effects on the central nervous system and blood cell counts.

Choice D reason:
A WBC count of 3,300/mm³ indicates leukopenia, which is a significant contraindication for chlorpromazine. This medication can cause agranulocytosis, a severe reduction in white blood cells, making patients more susceptible to infections. Therefore, a low WBC count is a critical factor in deciding against the use of chlorpromazine.

A. Place the client in seclusion if visual hallucinations are present. B. Limit the number of questions asked during assessments. C. Use frequent touch to provide client support. D. Directly tell the client that delusions are not real.

Correct Answer is B

Explanation

Choice A reason:
Placing the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention. Seclusion should only be used when the client poses an immediate threat to themselves or others and less restrictive measures have failed. It is important to use the least restrictive interventions to manage symptoms.

Choice B reason:
Limiting the number of questions asked during assessments can help reduce the client’s anxiety and prevent overwhelming them. Clients with schizophrenia may have difficulty processing information and may become more paranoid or distressed with too many questions. This approach helps create a more supportive and manageable environment for the client.

Choice C reason:
Using frequent touch to provide client support is not recommended for clients with paranoid delusions. Physical touch may be misinterpreted as a threat or invasion of personal space, exacerbating the client’s paranoia and anxiety. It is important to respect the client’s boundaries and use other forms of support.

Choice D reason:
Directly telling the client that delusions are not real can be confrontational and may increase the client’s distress. Instead, the nurse should acknowledge the client’s feelings and provide reassurance without directly challenging their beliefs. This approach helps maintain a therapeutic relationship and supports the client’s emotional well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has a new prescription for chlorpromazine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to chlorpromazine?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, “My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?” Which of the following responses should the nurse make?