A client diagnosed with schizophrenia disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop the psychiatrist." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?
Altered thought processes; call an emergency treatment team meeting.
Command hallucinations; warn the psychiatrist.
Persecutory delusions; orient the client to reality.
Magical thinking; administer an antipsychotic medication.
The Correct Answer is B
a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Food is rapidly ingested without proper chewing: While this might happen in bulimia nervosa, it does not explain dental erosion.
b. Purging causes the depletion of dietary calcium: Calcium depletion could affect bones and teeth but is not the primary reason for the dental erosion seen in bulimia nervosa.
c. Poor dental and oral hygiene lead to dental caries: While poor hygiene can contribute to dental issues, the primary cause of dental deterioration in bulimia is the acid from vomiting.
d. Emesis from purging corrodes the tooth enamel. Frequent vomiting in bulimia nervosa exposes teeth to stomach acid, which erodes the enamel and leads to dental deterioration.
Correct Answer is C
Explanation
a. "I can make that promise to you based on nurse-client privilege." Nurse-client confidentiality is important, but it doesn't apply to threats of violence. The nurse has a duty to protect the client and others.
b. "Those kinds of thoughts will make your hospitalization longer." While true, this response doesn't directly address the safety concern and might be perceived as judgmental.
c. "I cannot promise that. Confidentiality does not include plans to hurt others." This is a clear and honest statement. It explains the limitations of confidentiality and prioritizes safety.
d. "You should share this thought with your psychiatrist." While encouraging the client to talk to a psychiatrist is a good suggestion, it doesn't directly address the confidentiality issue or the immediate threat.
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