The parents of a young adult diagnosed with schizophrenia are providing care for the client in their home. During a home visit, the parents state, “it’s been so difficult taking care of our child. We need a break. But our child needs constant supervision.” Which would be appropriate for the nurse to suggest?

Respite residential care

Acute inpatient care

Intensive outpatient program

Partial hospitalization

Answer and Explanation

The Correct Answer is A

Choice A reason:
Respite residential care provides temporary relief for caregivers by offering short-term care for individuals with chronic conditions like schizophrenia. This option allows the parents to take a break while ensuring that their child receives the necessary supervision and care in a safe environment. Respite care can help prevent caregiver burnout and provide a much-needed rest for the family.

Choice B reason:
Acute inpatient care is designed for individuals experiencing severe psychiatric crises that require immediate and intensive treatment. While it provides comprehensive care, it is not typically used for respite purposes. This option is more appropriate for situations where the client poses a danger to themselves or others and needs stabilization.

Choice C reason:
An intensive outpatient program (IOP) offers structured treatment while allowing the client to live at home. It is suitable for clients who need more support than traditional outpatient care but do not require 24-hour supervision. However, it does not provide the temporary relief that respite care offers to caregivers.

Choice D reason:
Partial hospitalization programs (PHP) provide intensive treatment during the day, allowing clients to return home in the evening. While PHPs offer substantial support, they do not address the need for temporary relief for caregivers. Respite care is specifically designed to give caregivers a break from their responsibilities.

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Correct Answer is B

Explanation

Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.

Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.

Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.

Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.

A. Anticipate removing the restraints every 4 hours. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Ensure four fingers fit under the restraints to prevent constriction.

Correct Answer is C

Explanation

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.

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Naxlex Comprehensive Predictor Exams

During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

Correct Answer is B

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

When applying the biopsychosocial model to a client with a mental health problem, the nurse addresses which psychological domain?

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply)

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?

After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?