The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?

Check to see what medication the client is taking.

Encourage the client to eat more slowly.

Assessment security.

Assess the client more thoroughly and immediately report any concerns to the provider.

Answer and Explanation

The Correct Answer is D

A.   While medication review may be necessary, the immediate concern is the client's current symptoms and potential need for urgent intervention.
B.   Encouraging the client to eat more slowly does not address the urgent nature of the client's symptoms.

C.   "Assessment security" is not a standard term or intervention. It does not provide specific guidance for addressing the client's symptoms.
D.   Given the client's complaints of swelling and tightness, along with difficulty swallowing, further assessment is needed to determine the cause. This information should be reported to the provider promptly.

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Correct Answer is A

Explanation

A) Correct. An idea of reference is a false belief that ordinary events, objects, or behaviors of others have a particular and unusual meaning directly pertaining to oneself. In this case, the client believes that the doctors' conversation in the hall is about them.

B) Incorrect. A delusion of infidelity involves a false belief that one's partner is being unfaithful.
C) Incorrect. Auditory hallucinations involve hearing things that are not present.
D) Incorrect. Echolalia is the repetition of another person's words.

A. Plan to discuss any topic that is presented. B. Focus on client weaknesses to increase adaptation. C. Provide continuity of care by assigning the same staff. D. Allow client to determine the boundaries of the nurse client relationship.

Correct Answer is C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

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The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly admitted client diagnosed with paranoid schizophrenia is super vigilant and constantly scans the environment. The client states, "I saw doctors talking in the hall. They were plotting to kill me." Which of the following does the nurse correctly identify as this behavior?

Correct Answer is A

Explanation

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is C

Explanation

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