On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, "I am the son of God." Based on this statement, which intervention should the nurse include in this client's plan of care?

Confront the client's delusion as not consistent with reality.

Schedule activity therapy twice weekly.

Ensure the client's environment is safe.

Lead the client by the arm to the seclusion room.

Answer and Explanation

The Correct Answer is C

Choice A reason: Confronting delusions directly can increase agitation and disrupt therapeutic rapport in schizophrenia. Ensuring a safe environment addresses potential risks from delusional behavior without challenging beliefs, aligning with psychiatric nursing principles for managing psychosis, making this incorrect for the care plan.

Choice B reason: Activity therapy supports socialization but does not address the immediate safety needs posed by the client’s delusion. Ensuring a safe environment prevents harm related to grandiose beliefs, making this intervention secondary and incorrect compared to prioritizing safety in acute schizophrenia management.

Choice C reason: Ensuring a safe environment is critical for a client with schizophrenia expressing delusions, as grandiose beliefs may lead to risky behaviors. This intervention minimizes harm while supporting therapeutic engagement, aligning with safety-first psychiatric care principles, making it the most appropriate care plan inclusion.

Choice D reason: Leading the client to seclusion is overly restrictive and unwarranted based solely on a delusion, which is not inherently dangerous. Ensuring safety through environmental management is less invasive and more therapeutic, making seclusion incorrect for managing this client’s delusional statement.

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Correct Answer is C

Explanation

Choice A reason: Quoting “My date raped me tonight” is specific but may be too detailed for the chief concern, which should be concise and objective. “Sexually assaulted” is a clear, professional term that captures the event without verbatim quotes, making this less optimal for EMR documentation.

Choice B reason: “Claims” and “forced to participate” may imply doubt about the client’s report, which is untherapeutic and inappropriate. “Sexually assaulted” is a neutral, factual term that respects the client’s experience, making this choice less sensitive and incorrect for the chief concern documentation.

Choice C reason: Documenting “Client has been sexually assaulted” is concise, objective, and professional, accurately reflecting the chief concern without judgment or excessive detail. This aligns with trauma-informed care and EMR standards, making it the most appropriate choice for documenting the client’s reason for admission.

Choice D reason: “Sexual relations against her will” is vague and less precise than “sexually assaulted,” which is a recognized medical and legal term. This phrasing risks minimizing the assault, making it less appropriate and incorrect for clear, trauma-sensitive documentation in the EMR.

A. Observe the client for further narcotic effects. B. Encourage the client to increase fluid intake. C. Determine the client's reason for attempting suicide. D. Obtain the client's serum hydrocodone/acetaminophen level.

Correct Answer is A

Explanation

Choice A reason: Observing for further narcotic effects is the highest priority, as naloxone’s short half-life may allow hydrocodone’s respiratory depression to recur. Ensuring respiratory and neurological stability post-reversal is critical, aligning with toxicology protocols for opioid overdose, making this the most urgent nursing intervention.

Choice B reason: Increasing fluid intake is not urgent post-naloxone, as hydration does not address immediate risks like recurrent opioid effects. Monitoring for respiratory depression takes precedence to ensure safety, making this incorrect for the highest-priority intervention in the client’s post-overdose care plan.

Choice C reason: Determining the reason for the suicide attempt is important for psychiatric care but secondary to monitoring for recurrent opioid effects, which pose an immediate life-threatening risk. Safety via observation is the priority, making this incorrect for the initial post-naloxone intervention.

Choice D reason: Obtaining serum hydrocodone levels is unnecessary post-naloxone, as clinical response guides treatment. Monitoring for recurrent narcotic effects ensures safety, as naloxone’s effects may wear off. This is less critical, making it incorrect for the highest-priority intervention in acute overdose management.

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On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, "I am the son of God." Based on this statement, which intervention should the nurse include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young female client is admitted to the emergency department because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client’s chief concern?

Correct Answer is C

Explanation

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. While planning nursing care, which intervention has the highest priority at this time?

Correct Answer is A

Explanation

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