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
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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Related Questions
Correct Answer is A
Explanation
A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.
Correct Answer is C
Explanation
A. While understanding precipitating factors is important, it is not the immediate priority when the client is actively experiencing hallucinations.
B. Distracting the client may not address the underlying cause of the hallucinations, which should be the priority.
C. Determining the content of the hallucinations can provide important information for assessment and intervention.
D. Dismissing the client's experience can be alienating and unhelpful.
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