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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Correct Answer is B

Explanation

Choice A reason: Intensive Outpatient Programs (IOPs) offer structured treatment for mental health and substance misuse concerns, providing therapy for a few hours a day, several days a week. While beneficial, they may not offer the comprehensive, round-the-clock support needed by someone with a chronic mental illness.

Choice B reason: Assertive Community Treatment (ACT) is a form of community-based mental health care designed to help individuals with serious mental illnesses manage their symptoms and live independently in the community. ACT involves a multidisciplinary team approach and provides round-the-clock services, making it an ideal resource for chronic mental illness management.

Choice C reason: Patient-Centered Medical Homes (PCMHs) focus on providing comprehensive, coordinated care that is patient-centered and culturally appropriate. Although PCMHs offer a broad range of services, they may not be as intensive as ACT for managing chronic mental illness.

Choice D reason: Partial Hospitalization Programs (PHPs) are intensive outpatient treatment programs that allow patients to live at home while receiving daily treatment at a facility. PHPs are more intensive than IOPs but less so than inpatient care, and they may not provide the continuous support that ACT offers for chronic mental illness.

A. The client appears to be well-groomed B. The client’s current weight is 54 kg (119 lb.) C. The client states they are sleeping 5 to 6 hours per night, but having an occasional nightmare D. The client verbalizes a decreased appetite and gastrointestinal discomfort E. The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.” F. The client verbalizes that bullying experienced during high school has led to anxiety G. The client engages in thought-stopping behavioral therapy and cognitive restructuring H. The client reports taking escitalopram 20 mg daily, 2 hours after breakfast

Correct Answer is ["A","C","G","H"]

Explanation

Being well-groomed can be an indicator of improved mental health, as it suggests the client is taking care of their personal hygiene and appearance, which can be neglected during severe anxiety episodes.

An increase in the amount of sleep and a decrease in the frequency of nightmares can be seen as an improvement in the client’s condition, as sleep disturbances are common in anxiety disorders.

Engagement in thought-stopping behavioral therapy and cognitive restructuring indicates that the client is actively participating in therapeutic activities designed to manage anxiety, which is a positive sign of improvement.

Consistent medication adherence, as reported by the client taking escitalopram 20 mg daily, is crucial for managing anxiety symptoms and indicates the client’s commitment to following the treatment plan.

The client’s weight remaining stable could be neutral, as it does not indicate a significant change. Verbalizing decreased appetite and gastrointestinal discomfort, feeling anxious about leaving the house, and stating that past bullying has led to anxiety are all signs that the client is still experiencing symptoms of anxiety. Therefore, these choices do not reflect an improvement in the client’s condition.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has obsessive-compulsive personality disorder (OCPD). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Correct Answer is ["A","C","G","H"]

Explanation

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A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

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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.)

A nurse is caring for a client who is receiving end-of-life care. The client states, "The nurses here don't do a good job caring for me." Which of the following responses should the nurse make?

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