During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Family history of schizophrenia.

History of suicide attempts.

Undiagnosed social anxiety symptoms (SAD).

Feelings of disorientation.

Answer and Explanation

The Correct Answer is B

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

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Correct Answer is C

Explanation

A. Listening for extra heart sounds, murmurs, and rhythm is important, but obtaining an ECG and starting continuous monitoring should be prioritized to assess for possible acute coronary syndrome.

B. Reducing environmental stimuli is beneficial for patient comfort but is not the immediate priority in assessing and managing potential cardiac events.

C. Obtaining a 12-lead electrocardiogram and beginning continuous cardiac monitoring are critical actions to diagnose and monitor for myocardial infarction or other cardiac events. These steps provide vital information for immediate treatment decisions.

D. Restricting family and visitors may be necessary but is not the immediate next action compared to performing an ECG and continuous monitoring to assess the client's cardiac status.

A. Shuffling gait and stooped posture. B. Rocks back and forth in the chair. C. Muscle spasms of the back and neck. D. Lip smacking and frequent eye blinking.

Correct Answer is C

Explanation

A. Shuffling gait and stooped posture are common side effects of antipsychotic medications and may require intervention but are not immediately dangerous.

B. Rocking back and forth in the chair can be a self-soothing behavior in individuals with schizophrenia and usually does not require immediate intervention.

C. Muscle spasms of the back and neck (dystonia) can be a sign of a serious side effect of antipsychotic medications known as extrapyramidal symptoms and require immediate intervention to prevent complications such as airway obstruction.

D. Lip smacking and frequent eye blinking can indicate tardive dyskinesia, a long-term side effect of antipsychotic medication, but it is not an immediate emergency.

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During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Correct Answer is C

Explanation

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID 19. Which action is most important for the nurse to take?