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:Citing personal reasons, such as needing to get home to family, is unprofessional and shifts focus away from the client’s needs. It does not address the client’s request or provide a constructive solution, making it an inappropriate response.
Choice B reason:Offering to do whatever the nurse can to help is vague and could imply willingness to perform prohibited tasks like shopping. This response risks crossing professional boundaries and is not appropriate.
Choice C reason:Suggesting the client wait for days when they feel better dismisses their current fatigue and inability to shop. It fails to offer immediate support or solutions, which is not helpful for an older adult needing assistance.
Choice D reason:Proposing to explore other resources, such as community services or family support, is appropriate because it respects the nurse’s professional boundaries while addressing the client’s needs. This response empowers the client by connecting them with sustainable solutions.
Correct Answer is B
Explanation
Choice A reason:Recalling past coping mechanisms can be helpful, but it is not the priority in acute anxiety. The client may be too overwhelmed to focus on strategies without first establishing a sense of safety.
Choice B reason:Remaining with the client is the priority, as it provides a calming presence, ensures safety, and helps reduce the client’s anxiety by offering immediate support and reassurance during an acute episode.
Choice C reason:Encouraging verbalization of feelings is therapeutic but not the priority in acute anxiety. The client may need time to calm down before they can effectively express their emotions.
Choice D reason:Providing a diverting activity may help manage mild anxiety but is not the priority in an acute, moderate episode. Staying with the client to ensure safety and reduce distress takes precedence.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.