While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Usual level of activity and average sleep pattern.

Blood pressure when sitting and standing.

Dentures to determine if they are poorly fitted.

Body weight over the past three months.

Answer and Explanation

The Correct Answer is C

A.   Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B.   Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D.   Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

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Correct Answer is B

Explanation

A. Sitting in the chair next to the client may be supportive but does not address the immediate concern of the client's behavior or hallucinations.
B. Listening to what the client is saying is crucial to understanding the content and nature of the auditory hallucinations, providing insight into the client's experience.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

A. Allow the adolescents to sit wherever they wish as long as they participate. B. Suggest that they all sit together to increase interaction. C. Ask the adolescent sitting on the couch to join the group at the table. D. Determine which adolescents would like to participate in the discussion.

Correct Answer is C

Explanation

A. While allowing freedom in choosing seats may be acceptable, in this scenario, encouraging a more cohesive and interactive group setting is beneficial.
B. Suggesting that they all sit together to increase interaction is a reasonable approach to enhance group dynamics.
C. Asking the adolescent sitting on the couch to join the group at the table promotes inclusivity and equal participation.
D. Determining which adolescents would like to participate may not be necessary; encouraging all to participate fosters a collaborative atmosphere.

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While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

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Naxlex Comprehensive Predictor Exams

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

Correct Answer is B

Explanation

The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

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While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

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