The practical nurse (PN) is performing a focused assessment for a client with schizophrenia who is admitted to an acute care inpatient facility. Which behavior should the PN document as a symptom of schizophrenia?
Frequent thoughts about ending his life.
Voices are telling the client to hurt himself.
Increasing memory lapses.
Periods of depression followed by feelings of euphoria.
The Correct Answer is B
A. Frequent thoughts about ending his life: Suicidal ideation is a serious finding but is not specific to schizophrenia. It is more indicative of mood disorders such as major depression and requires immediate safety intervention rather than defining schizophrenia.
B. Voices are telling the client to hurt himself: Auditory hallucinations, hearing voices that others do not hear, are a hallmark symptom of schizophrenia. Command hallucinations, where voices instruct the client to act, are particularly dangerous and require prompt intervention for safety.
C. Increasing memory lapses: Memory loss is more commonly associated with conditions such as dementia or delirium. While cognitive impairment can occur in schizophrenia, progressive memory loss is not a primary feature of the disorder.
D. Periods of depression followed by feelings of euphoria: Alternating episodes of depression and euphoria are characteristic of bipolar disorder, not schizophrenia. Schizophrenia is primarily marked by hallucinations, delusions, and disorganized thinking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Confirm that the medication is only administered once daily: The frequency of administration is verified when reviewing the prescription, not during the administration process. This step does not address the observed technique or ensure safe practice.
B. Determine if the medication is compatible with the solution: Checking compatibility is important before mixing medications with enteral feedings, but the question focuses on the PN’s observation of an improper administration technique, requiring immediate intervention.
C. Offer to assist in calculating the rate of flow for the mixture: Liquid medications given via feeding tubes are not typically infused at a specific rate but administered separately from feedings to prevent interaction or tube blockage, so rate calculation is unnecessary.
D. Demonstrate how to administer medication via a feeding tube: The appropriate response is to stop the incorrect procedure and demonstrate proper technique. Medications should be given separately from feedings, flushed with water before and after, and never mixed directly into the feeding solution.
Correct Answer is B
Explanation
A. Assign the UAP to more stable clients the next day: Changing assignments may reduce immediate risk but does not address the knowledge gap or prevent future errors. It is a reactive measure rather than a corrective one.
B. Supervise the UAP after reviewing the protocol: Reviewing the protocol and providing supervision ensures that the UAP understands the correct procedure and can implement it safely in the future. This action addresses the root cause of the omission and promotes adherence to safety standards.
C. Report the UAP's omission to the charge nurse: Reporting is appropriate if the error is serious or recurrent, but initial corrective action with education and supervision is typically preferred for a single omission, provided no harm occurred.
D. Complete an unusual occurrence report: An incident report may be required if the omission caused or had the potential to cause harm. In this scenario, implementing and supervising the correct procedure first takes priority to prevent patient risk.
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