A nurse on an inpatient mental health unit is admitting a client.

Exhibits

The nurse is reviewing the client's medical record at 0830 on day 2 of admission.

For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client's condition.

Blood pressure

Gait when ambulating

Lithium level

Urine amount and color

Blurred vision

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.

Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.

Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.

Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.

Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.

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Correct Answer is A

Explanation

A. Inability to concentrate is a common early sign of relapse in schizophrenia. It can indicate worsening symptoms and difficulty in maintaining focus and attention.
B. An inflated sense of self is not typically associated with relapse in schizophrenia. It may be a symptom of other psychiatric disorders, such as bipolar disorder or narcissistic personality disorder.
C. Increased sleeping can be a symptom of depression but is not specific to schizophrenia relapse.
D. Increased participation in social activities is not typically associated with relapse in schizophrenia. It may indicate improvement in social functioning or adaptation to the illness.

A. Place the client in a reclining chair. B. Put locks at top of doors. C. Encourage physical activity prior to bed time. D. Position the mattress on the floor. E. Install sensor devices on outside doors.

Correct Answer is ["B","C","D","E"]

Explanation

A. Placing the client in a reclining chair is not recommended as it does not prevent wandering or falls and may even restrict movement leading to discomfort or pressure sores.
B. Putting locks at the top of doors can prevent the client from wandering outside, which reduces the risk of falls and getting lost, especially during the night.
C. Encouraging physical activity prior to bedtime can help in expending energy which may lead to better sleep and reduce restlessness and wandering at night.
D. Positioning the mattress on the floor can minimize injury from falls that may occur when the client attempts to get out of bed during the night.
E. Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, which is crucial for preventing wandering and potential falls.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is caring for a client who is taking citalopram. For which of the following adverse effects should the nurse monitor the client?

A nurse is caring for a client who has been taking quetiapine for 1 week and reports dizziness. The client asks the nurse if the dizziness indicates an allergic reaction to the medication. Which of the following responses should the nurse make?

A nurse is caring for a client who is receiving inpatient treatment for an eating disorder. The client states, "I just can't sleep soundly here because It's too noisy." Which of the following actions should the nurse take?

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

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A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?