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 D
Explanation
Choice A reason: Initiating hospice care services is generally considered when the client is in the final stages of Alzheimer's disease and has a life expectancy of 6 months or less. Hospice care focuses on comfort and quality of life, rather than curative treatments. It's an option when the disease has significantly progressed, not typically at the time of initial diagnosis.
Choice B reason: Transcranial magnetic stimulation (TMS) is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain and is being studied as a potential treatment for improving cognitive status in Alzheimer's patients. However, it is not yet a standard treatment and is considered experimental.
Choice C reason: Barbiturate medications are not typically used to control anxiety in Alzheimer's patients due to the risk of dependency and the potential to worsen cognitive impairment. Other medications, such as selective serotonin reuptake inhibitors (SSRIs), are generally preferred for managing anxiety in these patients⁷.
Choice D reason: NMDA receptor antagonists, such as memantine, are medications that can help delay cognitive symptoms in patients with moderate to severe Alzheimer's disease. They work by regulating the activity of glutamate, a neurotransmitter involved in learning and memory, which may be overactive in Alzheimer's disease.
Correct Answer is D
Explanation
Choice A reason: Encouraging the client to internalize their feelings related to the loss is not advisable. Grief is a personal experience, and expressing emotions is a healthy part of the grieving process. Internalizing feelings can lead to unresolved grief and potential mental health issues.
Choice B reason: Changing the subject when the client expresses anger about their situation is not supportive. Anger is a natural stage of the grieving process, and it's important for the nurse to acknowledge the client's feelings and provide a safe space for them to express their emotions.
Choice C reason: Allowing the client to be alone during times of spiritual inadequacy may not be beneficial. While respecting the client's need for solitude is important, it's also crucial to offer support and presence, as isolation can exacerbate feelings of loneliness and despair.
Choice D reason: Offering to contact the client's spiritual advisor is a supportive action that can help meet the client's spiritual needs. Spiritual care is an integral part of holistic nursing care, and connecting the client with their spiritual support system can provide comfort and aid in the grieving process.
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