A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?

Note escalating behaviors and intervene immediately

interpret attempts at communication

Assess for medication noncompliance

Assess triggers for bizarre, inappropriate behaviors

Answer and Explanation

The Correct Answer is A

A. Note escalating behaviors and intervene immediately:

This option prioritizes the client's safety by addressing escalating behaviors promptly. Bizarre behaviors, neologisms, and thought insertion may indicate a severe episode of psychosis, and timely intervention is crucial to prevent harm to the client or others.

B. Interpret attempts at communication:

While understanding and interpreting communication are important, in a situation with escalating behaviors and potential safety concerns, immediate intervention takes precedence. Communication interpretation can follow once the safety of the client has been ensured.

C. Assess for medication noncompliance:

Medication noncompliance can contribute to exacerbation of symptoms, but in an acute situation where safety is a concern, addressing immediate behaviors takes precedence. Medication assessment can be done in the context of a more comprehensive assessment after the immediate safety concerns have been addressed.

D. Assess triggers for bizarre, inappropriate behaviors:

Identifying triggers is important for understanding the underlying causes of the behavior, but in the context of escalating behaviors and potential safety issues, immediate intervention to de-escalate the situation is the priority. Triggers can be explored once the immediate safety concerns are addressed.

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Correct Answer is D

Explanation

A. Provide client with high-calorie finger foods throughout the day:

While providing high-calorie finger foods may increase caloric intake, it may not be the most effective strategy for a specific weight gain goal. It's essential to encourage a balanced and varied diet.

B. Teach the importance of a varied diet to meet nutritional needs:

This is a good general approach to promote overall nutritional health, but it may not be specific enough to address the immediate goal of gaining 2 pounds within a week.

C. Initiate total parenteral nutrition to meet dietary needs:

Total parenteral nutrition is an invasive and aggressive intervention typically reserved for cases where oral or enteral feeding is not possible or insufficient. It is not the first-line approach for someone who can consume food orally.

D. Accompany client to cafeteria to encourage adequate dietary consumption:

This is the most appropriate intervention. Accompanying the client to the cafeteria provides an opportunity for direct encouragement and support during meals. It helps ensure that the client is consuming an adequate amount of food, which is crucial for the goal of gaining 2 pounds within a week.

A. Dry mouth and urinary retention B. Akinesia and insomnia C. Sore throat, fever, and malaise D. Akathisia and hypersalivation

Correct Answer is C

Explanation

A. Dry mouth and urinary retention: These symptoms are not typically associated with the side effects of clozapine. Dry mouth is a common side effect of many antipsychotic medications, but urinary retention is not a typical side effect of clozapine.

B. Akinesia and insomnia: Akinesia (lack of movement) is not a common side effect of clozapine. Insomnia can occur with various antipsychotic medications but does not typically warrant immediate intervention unless severe or persistent.

C. Sore throat, fever, and malaise: These symptoms can indicate a potentially serious side effect known as agranulocytosis, which is a significant reduction in white blood cell count. Clozapine is associated with an increased risk of agranulocytosis. If a client experiences symptoms such as sore throat, fever, or malaise, it may indicate a severe drop in white blood cell count, and immediate medical attention is necessary.

D. Akathisia and hypersalivation: Akathisia (restlessness) is a known side effect of antipsychotic medications, but it is not typically associated with immediate severe medical risks. Hypersalivation is a common side effect but does not usually require immediate intervention unless severe.

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A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?

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Naxlex Comprehensive Predictor Exams

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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