A nurse on an inpatient mental health unit is caring for a client.
The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.
Giving away car
Hygiene
Food intake
Condition of skin on right hand
Rapid change in mood
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood
Indicates potential worsening a. Giving away car b. Condition of skin on right hand
Choice A: Giving away car
This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.
Choice B: Hygiene
The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.
Choice C: Food intake
The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.
Choice D: Condition of skin on right hand
The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.
Choice E: Rapid change in mood
The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.
Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.
Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.
Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.
Correct Answer is A
Explanation
Choice A reason: Asking the client about their hallucinations can provide valuable information about the content and nature of the hallucinations. This can help the nurse assess the client's current mental state and the potential impact of the hallucinations on their behavior and safety.
Choice B reason: Focusing the client on reality-based topics is a strategy that can be used after understanding the client's hallucinations. It's important to first acknowledge the client's experience before attempting to redirect their attention.
Choice C reason: Taking the client for a walk may be a good distraction technique, but it should not be the first action. The nurse needs to assess the client's safety and the potential risks associated with the hallucinations before engaging in activities.
Choice D reason: Encouraging the client to listen to music can be a therapeutic intervention to help distract from hallucinations. However, it is not the first action to take. The nurse should first understand the client's experience and ensure their safety.
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