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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Is pathological and warrants postponing the test: Not necessarily true. Mild anxiety is a normal human response to stressful situations. Postponing the test might reinforce avoidance behaviors.
b. May be transferred to classmates and result in test anxiety: While anxiety can be contagious in some situations, the nurse should focus on calming techniques for the individual experiencing it, not assuming it will spread.
c. is conducive to concentration and problem solving (Correct): Mild anxiety, also known as arousal, can heighten focus and alertness. This can be beneficial for tasks that require concentration, like tests. In some cases, it can improve cognitive function
d. Will interfere with cognitive ability: Extreme anxiety can be debilitating, but mild anxiety can actually enhance focus and performance in some situations.
Correct Answer is A
Explanation
a. 1030-1130: Insulin aspart is a rapid-acting insulin that typically peaks in 1-2 hours. Hypoglycemia is most likely to occur during the peak action time.
b. 1130-1230: This is beyond the typical peak action time for insulin aspart, making hypoglycemia less likely during this interval.
c. 1000: This falls within the typical peak action time of 1-2 hours for insulin aspart, making hypoglycemia possible but the interval is slightly too narrow to capture the full peak effect.
d. 0800-0830: Insulin aspart begins to act within 10-20 minutes, but hypoglycemia typically does not occur this soon after administration unless there is an issue with meal timing or dosage.
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