A nurse in a mental health facility is admitting a client who was brought in by the police department.

Exhibits

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

A. Hallucinations B. Temperature C. Weight gain D. Blood pressure

Correct Answer is B

Explanation

Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Exhibits A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is B

Explanation

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