A 28-year old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

Orienting the client to the unit

Reinforcing reality with the client

Establishing a nonthreatening relationship

Assessing the client for physical problems

Answer and Explanation

The Correct Answer is D

A. Orienting the client to the unit While orientation is important, the client's prolonged
immobility and stupor necessitate a physical assessment first to ensure there are no underlying medical issues contributing to this state.

B. Reinforcing reality with the client The client's catatonic state may make it difficult to effectively communicate or engage in reality orientation at this point. Addressing potential physical issues is the initial priority.

C. Establishing a nonthreatening relationship Building a therapeutic relationship is crucial, but given the client's current state, assessing for physical problems takes precedence.

D. Assessing the client for physical problems The client's prolonged catatonic state requires an
immediate physical assessment to rule out any underlying medical conditions contributing to his condition.

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Correct Answer is C

Explanation

Confabulation involves the fabrication of details or events to fill in gaps in memory. In this case, the client is expressing happiness about a trip to the park that did not actually occur, which is an example of confabulation.

A. "Are you experiencing a relapse?" B. "What time was your last drink?" C. "How long have you had a problem with alcohol?" D. "Are you having any liver problems?"

Correct Answer is B

Explanation

A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.

B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.

C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.

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A 28-year old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing documentation entry accurately describes a client's use of confabulation?

Correct Answer is C

Explanation

A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?

Correct Answer is B

Explanation

A client with schizophrenia has begun a new prescription of clozapine. The nurse should assess the result of which laboratory study to monitor for adverse effects?

Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

A client asks the nurse to give her information regarding the detoxification process of alprazolam. What is the best response by the nurse?

A client is showing early signs of dementia. The client's spouse asks, "What may I expect next?" What is the nurse's best response?

The nurse is teaching about obstacles to maintaining recovery. Which of the following statements would indicate to the nurse a greater risk for relapse? (Select all that apply.)

The nurse is caring for a client diagnosed with premenstrual dysphoric disorder. What is the primary manifestation of this disorder?

The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?

Which statement made by the nurse would be most appropriate to an elderly client who is confused, has no history of dementia and is hospitalized for an acute urinary tract infection?