A 25-year-old male with schizophrenia is brought to the emergency department by his family. He is exhibiting severe agitation, auditory hallucinations, and paranoid delusions. What are the nursing priorities for managing this patient in an acute situation?
(Select All that Apply.)
Administer prescribed antipsychotic medication as ordered.
Ensure the patient is in a safe environment to prevent harm to himself or others.
Monitor the patient for any side effects of medications.
Leave the patient alone to calm down in a quiet room.
Establish a relationship by using calm and clear communication.
Encourage the patient to participate in group therapy immediately.
Ignore the patient’s hallucinations and delusions to avoid reinforcing them.
Provide the patient with detailed explanations of their condition and treatment plan.
Correct Answer : A,B,C,E
Choice A reason: Administering prescribed antipsychotic medication is a priority in acute psychotic episodes to reduce agitation, control hallucinations, and stabilize thought processes. Prompt pharmacologic intervention can prevent escalation of symptoms and potential harm.
Choice B reason: Ensuring a safe environment is essential because patients experiencing psychosis are at increased risk of self-harm or harming others due to delusions and impaired judgment. Safety is always the first priority in emergency psychiatric care.
Choice C reason: Monitoring for side effects of medications is necessary because antipsychotics can cause acute adverse reactions such as dystonia, akathisia, or even neuroleptic malignant syndrome. Early recognition and intervention can prevent complications.
Choice D reason: Leaving the patient alone while highly agitated is unsafe, as the patient may harm themselves or others. Continuous supervision and therapeutic presence are needed.
Choice E reason: Using calm and clear communication builds trust, reduces paranoia, and helps orient the patient. Clear, simple language is effective when the patient’s cognitive processing is impaired.
Choice F reason: Group therapy is inappropriate during acute agitation. The patient must first stabilize before being introduced to therapeutic group settings.
Choice G reason: Ignoring hallucinations and delusions is not therapeutic. While the nurse should not reinforce false beliefs, acknowledging the patient’s feelings and providing reality orientation is best practice.
Choice H reason: Providing detailed explanations about the condition and treatment during acute psychosis is ineffective. The patient is unlikely to process complex information until stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Directly rejecting the belief is non-therapeutic and may increase defensiveness, damaging trust.
Choice B reason: Telling the client to stop worrying invalidates their feelings and dismisses the emotional impact of the delusion.
Choice C reason: Participating in the delusion by “looking for cameras” reinforces the false belief, which is not supportive of reality testing.
Choice D reason: Acknowledging the client’s fear while gently presenting reality and shifting toward problem-solving helps maintain trust and supports reality testing.
Correct Answer is D
Explanation
Choice A reason: Zero capsules means the patient would not receive treatment.
Choice B reason: Three capsules equal 60 mg, which is an overdose compared to the prescribed 40 mg.
Choice C reason: One capsule equals 20 mg, which is only half the prescribed daily dose.
Choice D reason: Two capsules equal 40 mg, which matches the prescribed dose exactly.
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