A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

Give the client a schedule of planned daily activities.

Engage the client in a game of cards.

Encourage the client to have lunch off the unit.

Complete an assessment of social support.

Answer and Explanation

The Correct Answer is A

A)   Correct- this can help them structure their time, reduce boredom and anxiety, and increase their sense of control and achievement. This can also foster social interaction and engagement with the staff and peers. A schedule of planned daily activities is consistent with the principles of psychosocial rehabilitation, which is an evidence-based approach for people with schizophrenia.
B)   Incorrect- this may be too challenging or stressful for the client, especially if they have cognitive impairments or negative symptoms.
C)   Incorrect- may expose them to unfamiliar or unpredictable situations that could trigger or worsen their psychotic symptoms.
D)   Incorrect- it is not an intervention that directly addresses the client's current problem of social isolation.

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Correct Answer is A

Explanation

A.Tingling on the tongue or lips is an early sign of an allergic reaction to the contrast dye used during an intravenous pyelogram. This type of reaction can quickly progress to more severe symptoms, such as difficulty breathing and anaphylaxis, so it is crucial to recognize and respond to it promptly.

B. Episodes of shivering: Shivering is not typically an early sign of an allergic reaction to contrast dye. It might indicate a reaction to temperature or anxiety but is not as immediately concerning as symptoms of an allergic reaction.

C. Salty taste in the mouth: A salty or metallic taste is a common and benign side effect of the contrast dye and is not indicative of an adverse reaction.

D. Difficulty breathing: Difficulty breathing is a severe and later sign of an allergic reaction. By the time this symptom appears, the reaction has progressed and immediate intervention is necessary.

A. Administer a prescribed PRN dose of hydralazine. B. Assess the client's blood pressures every 15 minutes. C. Teach the client to recognize the symptoms of dysreflexia. D. Relieve any kinks or obstruction in the client's Foley tubing.

Correct Answer is D

Explanation

A) This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B) Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C) Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D) The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.

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A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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