A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Disrupts group activities.

Refuses antipsychotic medications.

Wanders into client's rooms.

Talks with nonsensical words.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Disrupting group activities is a concerning behavior but may not necessitate constant observation. The key is to assess the potential for harm to self or others.

Choice B rationale: Refusing antipsychotic medications is a significant concern, but it alone may not warrant constant observation. The nurse needs to assess the client's overall behavior and the potential for harm.

Choice C rationale: Wandering into clients' rooms poses a risk to the safety of both the client and others. This behavior indicates a need for constant observation to prevent harm or inappropriate interactions.

Choice D rationale: Talking with nonsensical words is a symptom of the client's mental health condition but may not be the sole criterion for constant observation. The nurse should assess the overall risk to safety.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.

Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.

Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.

Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.

A. Fear of large dogs. B. Decreased attention to detail. C. Social withdrawal. D. Changes in appetite.

Correct Answer is C

Explanation

Choice A rationale: Fear of large dogs may or may not be related to schizophrenia; other information is needed to determine its significance.

Choice B rationale: Decreased attention to detail is a symptom that may be observed in schizophrenia, but it is not the primary behavior to notify the healthcare provider.

Choice C rationale: Social withdrawal is a concerning behavior in schizophrenia that may indicate worsening symptoms and should be reported to the healthcare provider.

Choice D rationale: Changes in appetite are important to monitor but may not be the primary indicator of a worsening condition in schizophrenia.

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A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

Correct Answer is C

Explanation

When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide?

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A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

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