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 A
Explanation
Choice A reason:Sublimation is a defense mechanism where negative emotions, like anger, are channeled into positive or socially acceptable activities, such as exercise. Working out in the gym when feeling mad transforms the emotion into a constructive outlet, reflecting adaptive use of sublimation.
Choice B reason:Forgetting the event suggests repression or dissociation, not sublimation. This response does not involve channeling emotions into productive activities and is not adaptive for addressing anxiety.
Choice C reason:Denying anxiety indicates denial, not sublimation. This statement avoids acknowledging the emotion rather than redirecting it into a positive action, making it non-adaptive.
Choice D reason:Expressing inability to move past the tragedy reflects rumination or despair, not sublimation. It does not involve transforming negative emotions into constructive behaviors, so it is not an adaptive response.
Correct Answer is A
Explanation
Choice A reason:Major depressive disorder carries a high risk of suicide, especially in acute settings. Monitoring for self-harm is the priority to ensure the client’s safety, as it addresses an immediate, life-threatening risk before other interventions.
Choice B reason:Administering antidepressants is important for managing depression, but it is not the priority over safety. Antidepressants take weeks to become effective, and the risk of self-harm must be addressed first.
Choice C reason:Assisting with activities of daily living supports the client’s functional needs, but it is not the priority. Safety concerns, such as self-harm risk, take precedence in acute depression.
Choice D reason:Encouraging fluid intake is important for physical health, but it is not the priority in major depressive disorder. Preventing self-harm is critical due to the high risk of suicide in this condition.
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.