A nurse in a mental health facility is admitting a client who was brought in by the police department.
Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition:
a) Schizophrenia
Choice A reason: Schizophrenia is a chronic mental health condition characterized by symptoms such as delusions, hallucinations, disorganized speech, and significant social or occupational dysfunction. The client’s symptoms, including mumbling as if talking to unseen others and the belief that someone is trying to poison them, are indicative of psychotic features commonly associated with schizophrenia. The prescribed medications, clozapine and risperidone, are antipsychotics often used in the treatment of schizophrenia, further supporting this diagnosis.
Actions to Take:
d) Place the client in a room near the nurses’ station This action allows for close observation and quick intervention if the client’s condition worsens or if they exhibit behaviors that could be harmful to themselves or others.
f) Maintain the client taking their prescribed medications Continuing the prescribed antipsychotic medications is crucial for managing the symptoms of schizophrenia and preventing exacerbation of the condition.
Parameters to Monitor:
j) Command hallucinations Monitoring for command hallucinations is important as they can lead to dangerous behaviors, including harm to self or others, if the client acts on these hallucinations.
l) Suicidal ideation Patients with schizophrenia are at an increased risk for suicide, especially during acute episodes or when experiencing command hallucinations. Regular assessment for suicidal ideation is a critical component of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This response may seem dismissive and could minimize the client's feelings. It's important to acknowledge the client's emotions as valid and unique to their experience, rather than comparing them to others.
Choice B reason: This response invites the client to share their feelings in a non-judgmental space and shows the nurse's willingness to listen. It respects the client's autonomy and provides an opportunity for them to open up about their concerns at their own pace.
Choice C reason: While this response is meant to be reassuring, it may inadvertently invalidate the client's feelings. Embarrassment is a personal emotion, and what might seem trivial to one person can be significant to another.
Choice D reason: This response implies that sharing will lead to relief, which may not always be the case. It also puts pressure on the client to disclose information before they are ready, which could be counterproductive.
Correct Answer is D
Explanation
Choice A reason: While discussing the client's diagnosis with their family could be part of the care process, it does not address the client's immediate concern about the quality of care they are receiving. This response does not validate the client's feelings or provide an opportunity for them to elaborate on their concerns.
Choice B reason: Telling the client that their feelings are part of anticipatory grieving may be true, but it can come across as dismissive and does not offer support for the specific issue the client has raised about the quality of care.
Choice C reason: Assuring the client that the nurses are trying to provide good care does not acknowledge the client's perception of inadequate care. It's important to validate the client's feelings and understand their perspective before offering reassurances.
Choice D reason: Asking the client to elaborate on their concerns shows empathy and a willingness to listen. It allows the nurse to gather more information about the client's experience and identify specific areas that may need improvement in the care provided.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.