A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Set limits on the amount of time the client talks about delusions,

Schedule a variety of competitive stimulating group activities for the client

Tell the client that the delusions are not real

Avoid asking the client about triggers for the delusions

Answer and Explanation

The Correct Answer is A

A. Set limits on the amount of time the client talks about delusions. Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.

B. Schedule a variety of competitive stimulating group activities for the client. Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.

C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.

D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.

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Correct Answer is C

Explanation

A. Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia.

B. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation.

C. Pupillary constriction (miosis).
Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness.

D. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.

A. Blood pressure B. Lack of motivation C. Change in behaviour D. Lack of energy E. Withdrawn

Correct Answer is ["B","D","E"]

Explanation

The "3" findings that should indicate to the nurse that the client is experiencing negative symptoms related to their schizophrenia are:
B.Lack of motivation
D.Lack of energy
E.Withdrawn
Explanation:
Negative symptoms in schizophrenia involve deficits or reductions in normal emotional and behavioral functioning. In the provided nurse's notes:

Blood pressure: Blood pressure is not mentioned in the nurse's notes, and it is not directly indicative of negative symptoms in schizophrenia.

B. Lack of motivation: The client refusing to eat or drink, not engaging in conversation, and not wanting to go to therapy sessions are indicative of a lack of motivation, which is a negative symptom.

C. Change in behavior: While there is a change in behavior mentioned in the notes (refusing to eat or drink, not engaging in conversation), the specific behavioral changes described are more closely associated with negative symptoms. Negative symptoms involve a reduction or loss of normal functions.

D. Lack of energy: The client's slow movements and desire to sleep suggest a lack of energy, another negative symptom associated with schizophrenia.

E. Withdrawn: The client's withdrawal from social interaction, as evidenced by not engaging in conversation and wanting to sleep, is characteristic of withdrawal, which is a negative symptom.

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A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?

Correct Answer is C

Explanation

A nurse is caring for a client who has schizophrenia. Exhibits Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.

Correct Answer is ["B","D","E"]

Explanation

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