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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
Correct Answer is C
Explanation
Choice A rationale: Telling the client that irrational thinking is a symptom of schizophrenia may not be well-received and could lead to increased resistance. It is essential to address the immediate concern of food refusal.
Choice B rationale: Assuring the client that all food served in the hospital is safe to eat may not be sufficient, especially if the client has strong delusional beliefs about poisoning. Offering food in unopened containers is a more practical approach. Choice C rationale: Providing the client with food in unopened containers is a reasonable intervention. It addresses the client's concerns about poisoning and ensures that the food is perceived as safe.
Choice D rationale: Obtaining an order for a tube feeding for the client may be considered if the client continues to refuse solid food. However, providing food in unopened containers is an initial step to encourage the client to eat.
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