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:Prayer can be an effective stress management technique for some individuals, as it promotes relaxation and emotional grounding, particularly for those with spiritual beliefs, making it a helpful strategy.
Choice B reason:Journaling is an effective way to process emotions and reduce stress, especially when verbal expression is challenging. It allows clients to reflect and manage anxiety constructively.
Choice C reason:Exercise is a well-established stress management technique, as it reduces tension, releases endorphins, and promotes physical and mental well-being, making it effective for stress relief.
Choice D reason:Consuming coffee, a stimulant, can worsen anxiety by increasing heart rate and nervousness. This is the least effective technique, as it may exacerbate stress rather than alleviate it.
Correct Answer is C
Explanation
Choice A reason:Cottage cheese is a low-tyramine food and generally safe for patients taking monoamine oxidase inhibitors (MAOIs) like phenelzine. It does not pose a significant risk of causing a hypertensive crisis, which is a concern with MAOIs due to their interaction with tyramine-rich foods.
Choice B reason:Shellfish is not typically high in tyramine, the compound that can cause dangerous interactions with MAOIs. While food safety (e.g., avoiding spoiled shellfish) is important, shellfish does not need to be avoided specifically due to phenelzine use.
Choice C reason:Salami, a cured meat, is high in tyramine, which can interact with MAOIs like phenelzine. This interaction can lead to a hypertensive crisis, characterized by dangerously high blood pressure, headaches, and other serious symptoms. Patients on MAOIs must avoid tyramine-rich foods like aged meats, cheeses, and fermented products.
Choice D reason:Frozen peas are not high in tyramine and do not pose a risk when taken with MAOIs. They are generally safe for consumption and do not require dietary restrictions for patients on phenelzine.
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