Exhibits
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Hallucinations
Temperature
Weight gain
Blood pressure
The Correct Answer is B
Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While a unit secretary who speaks the same language could potentially communicate with the client, they may not be trained in medical terminology or confidentiality practices. Effective communication in healthcare settings requires more than just language proficiency; it involves understanding the nuances of medical dialogue and ensuring privacy and accuracy.
Choice B reason: Relying on another client for translation is not advisable. This could breach confidentiality, and the other client may not have the necessary skills to translate medical information accurately. Additionally, it places an undue burden on the client, who is there to receive support, not to provide services.
Choice C reason: A professional translator, preferably of the same gender as the client if it makes the client more comfortable, is the best option. Professional translators are trained to handle medical terminology and to navigate the cultural nuances that may arise in communication. They are also bound by confidentiality agreements to protect the client's privacy³.
Choice D reason: While a family member may be able to communicate effectively in the client's language, there are potential issues with privacy, accuracy, and dynamics that could affect the client's comfort and willingness to share openly in a support group setting. Family members may also unintentionally alter or withhold information based on their own biases or desires.
Correct Answer is B
Explanation
Choice A reason: Asking "Why did you feel like giving away your belongings?" could be perceived as confrontational or judgmental. It's important to approach the client with empathy and without implying that their actions were wrong or require justification.
Choice B reason: "Can you tell me how you have been feeling lately?" is an open-ended question that invites the client to share their feelings and experiences. It demonstrates the nurse's interest in understanding the client's emotional state and provides a safe space for the client to express themselves.
Choice C reason: Saying "Everyone feels a little down sometimes." minimizes the client's experience and the severity of major depressive disorder. It fails to acknowledge the unique and serious nature of the client's condition.
Choice D reason: While suggesting "You should find a support group to attend." can be helpful, it may be more appropriate after establishing a rapport and understanding the client's current state. It's also important to offer support in finding resources rather than directing the client.
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