A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

Flight of ideas

Decreased motivation

Impaired memory

Delusions of grandeur

Auditory hallucinations

Answer and Explanation

Correct Answer : A,D,E

Positive symptoms of schizophrenia are those that add something to the normal experience, such as hallucinations, delusions, disorganized speech, and abnormal motor behavior. Flight of ideas is a type of disorganized speech that involves rapid switching from one topic to another. Delusions of grandeur are false beliefs of having superior power or status. Auditory hallucinations are hearing voices or sounds that are not real. Negative symptoms of schizophrenia are those that take something away from the normal experience, such as decreased motivation, impaired memory, flat affect, and social withdrawal.

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Correct Answer is D

Explanation

Clozapine is an antipsychotic medication that can cause agranulocytosis, a potentially life-threatening condition that reduces the number of white blood cells and increases the risk of infection. A sore throat is a sign of infection and should be reported immediately. The other clients are not in immediate danger and can be seen later.

A. Stop the newly licensed nurse from administering the medication. B. Demonstrate how to verbally de-escalate the situation. C. Discuss the purpose of the medication with the client. D. Assess the need for physical restraints.

Correct Answer is B

Explanation

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

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A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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