A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
Stop the car in the client's driveway and call the authorities.
Honk the car horn to get the client's attention.
Calmly speak the client's name out of the car window.
Keep driving in a path that is going away from the client's house.
The Correct Answer is D
Choice A reason:
Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.
Choice B reason:
Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.
Choice C reason:
Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.
Choice D reason:
Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Blunted affect refers to a significant reduction in the intensity of emotional expression. In the context of schizophrenia, a person with blunted affect may show less facial expression, have diminished expressive gestures, and a monotone voice. This symptom reflects a decrease in the expression of emotions, which is characteristic of the negative symptoms of schizophrenia.
Choice B Reason:
Delusions are a type of positive symptom of schizophrenia, not a negative one. They are false beliefs that are not based in reality, such as thinking one has superpowers or is being persecuted. Delusions represent an excess or distortion of normal functions.
Choice C Reason:
Poor judgment is not typically classified as a negative symptom of schizophrenia. It can be a consequence of cognitive impairments or positive symptoms like delusions but is not a negative symptom itself.
Choice D Reason:
Anhedonia is the inability to feel pleasure and is a core negative symptom of schizophrenia. Individuals with anhedonia may not enjoy activities that they used to find pleasurable, which can significantly impact their quality of life.
Choice E Reason:
Hallucinations, like delusions, are considered positive symptoms of schizophrenia. They involve experiencing sensations that are not present, such as hearing voices or seeing things that others do not see.
Correct Answer is D
Explanation
Choice A Reason:
Scheduling the client for a therapeutic group session may not be appropriate as a priority action. Clients with catatonia often experience significant psychomotor disturbances, which can include immobility or stupor, making participation in group activities challenging and potentially distressing.
Choice B Reason:
Encouraging the client to walk in the hallway is not the most immediate concern. While mobility is important, the safety and medical stability of the client take precedence, especially considering the potential for immobility and resistance to movement in catatonic states.
Choice C Reason:
Encouraging the client to verbalize feelings at all times is not practical as a priority action. Catatonia can involve mutism or significantly reduced responsiveness, making it difficult for the client to express themselves verbally.
Choice D Reason:
Offering small, frequent fluids throughout the day is a priority action for a client with catatonia. Due to the potential for decreased oral intake and the risk of dehydration, ensuring the client receives adequate hydration is essential. This intervention addresses a basic physiological need and can prevent further complications.
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