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 A
Explanation
Choice A reason: Donepezil is often administered before bedtime to reduce the risk of nausea, which is a common side effect. Taking it at bedtime can also coincide with the body's natural rest period, potentially minimizing the impact of any side effects.
Choice B reason: Alzheimer's disease is a progressive condition, and currently, there is no cure. The provider will not decrease the dose as the disease improves because the disease typically worsens over time. Medication management may change, but it is based on symptom control, not improvement of the disease.
Choice C reason: Donepezil does not stop the progression of Alzheimer's disease. It can help manage symptoms and improve quality of life, but it does not cure or halt the disease's progression.
Choice D reason: Donepezil does not decrease the risk of falls. In fact, some of its side effects, such as dizziness, may increase the risk of falls. It is important for caregivers to monitor their partners for such side effects and take precautions to prevent falls.
Correct Answer is B
Explanation
Choice A reason: Telling the client that the symptoms will improve over time without further assessment could be misleading. These symptoms could indicate lithium toxicity, which requires immediate medical attention.
Choice B reason: Lethargy, muscle weakness, and blurred vision can be signs of lithium toxicity. The nurse should recommend blood tests to check lithium levels and kidney function to rule out toxicity.
Choice C reason: Decreasing sodium intake is not recommended without a healthcare provider's advice, as sodium levels can affect lithium levels in the body. Sudden changes in sodium intake should be avoided unless directed by a healthcare provider.
Choice D reason: Continuing the medication as prescribed without addressing the symptoms could be dangerous. The symptoms reported by the client need to be evaluated to ensure they are not due to lithium toxicity.
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